Air Blue crash was caused by Captain

[newscaster]

Some new information released, actual report was to be made public a few days back but hasnt come out yet.

Airblue inquiry finds captain uneasy, confused | Provinces | DAWN.COM (http://www.dawn.com/2011/12/22/airblue-inquiry-finds-captain-uneasy-confused-2.html)

DAWN, December 22, 2011

Headlines: Airblue inquiry finds captain uneasy, confusedWaseem Ahmad Shah | Peshawar | From the Newspaper (14 hours ago) Today

PESHAWAR, Dec 21: Inquiry into the last year’s Airblue plane crash into the Margalla Hills of Islamabad has said the captain showed signs of anxiety, preoccupation, confusion and geographical disorientation in various phases of the flight, especially after commencement of descent.

All 152 passengers and crew on board died in the July 28, 2010 incident.

The 38 pages inquiry report submitted to the Peshawar High Court by a team headed by Air Commodore Khwaja A Majeed a day ago said deteriorated weather conditions were a factor in the causation of the crash and that no evidence of any internal or external sabotage, incapacitation of aircraft systems, in-flight fire, bird strike or structural fatigue had been found.

According to the report, Airblue crash has been finalised as a case of Controlled Flight into Terrain (CFIT) in which aircrew failed to display superior judgment and professional skills in a self created unsafe environment.

“In their pursuit to land in inclement weather, they committed serious violations of procedures and breaches of flying discipline, which put the aircraft in an unsafe condition over dangerous terrain at low altitude.

“Captain Pervez Iqbal Chaudhry’s behaviour towards the flying officer was harsh, snobbish and contrary to establish norms. This undesired activity of the captain curbed the initiative of the first officer (FO), created a tense and undesirable environment, and a very conspicuous communication barrier in the cockpit, portraying a classic CRM (Crew Resource Management) failure.”

The report said the captain had prior knowledge of the decision by two captains flying ahead of him.

“While the captain of PK-356 managed to land in the third attempt, the captain of China Southern decided to divert back to Urumchi (China). The captain of the mishap flight opted to follow PK-356 but with non-standard approach procedure.”

The report said though aircrew captain was fit to undertake the flight on the mishap day, his portrayed behaviour and efficiency was observed to have deteriorated with the inclement weather at the Benazir Bhutto International Airport (BBIAP).

It further said the chain of events leading to the accident began with the commencement of the flight where the captain was heard to be confusing BBIAP, Islamabad, with HIAP (Jinnah International Airport), Karachi, while planning FMS (Flight Management System) and Khanpur Lake (Wah) with Kahuta area during holding pattern.

“This state continued when the captain of the mishap flight violated the prescribed Circling approach Procedure for RWY-12 by descending below Minimum Descent Allowed (i.e 2,300 feet instead of maintaining 2,510 feet) losing visual contact with the airfield, etc,” it said.

About the sequence of events, the report said during initial climb, the captain tested the knowledge of the FO and used harsh words and snobbish tone, contrary to the company procedure/norms.

“The question/answer sessions, lecturing and advices by the mishap, the captain continued with intervals for about one hour after takeoff. After the intermittent humiliating sessions, the FO generally remained quiet, became under confidence, submissive and subsequently did not challenge the captain for any of his errors, breaches and violations.”

It said the plane had ended up in a dangerous situation due to most unprofessional handling by the captain, adding that since the desired initiative of the FO had been curbed and a communication barrier had already been created by the captain the FO failed to intervene, take over the controls to pull the plane out of danger and display the required CRM skills.

“At 0441:08 hours, the FO was heard the last time saying to the captain ‘Sir we are going down, sir we are going da….’ The high rate of descend at very low altitude could not be arrested and the aircraft flew into the hill and was completely destroyed. All souls on board sustained fatal injuries due to impact force.”

The report said at 0439:58 (70 seconds before the impact), first Enhanced Ground Proximity Warning System (EGPWS) warning of ‘terrain ahead’ started sounding meaning that the EGPWS worked exactly in the manner for which it was designed. It is added that the aircrew ignored several calls by the ATS (Air Traffic Services) controllers and EGPWS system warnings (21 times) related to approaching terrain and pull up.

It further said flight recorders contained the complete flight data and cockpit voice recording for the entire flight duration from the takeoff to the crash.

[tsgas]

A very sad chain of events that led to so many lives being wasted.
I was taught that "Attitude is everything".

[bavarian-buddy]

Hard stuff.
" It is added that the aircrew ignored several calls by the ATS (Air Traffic Services) controllers and EGPWS system warnings (21 times) related to approaching terrain and pull up."
Almost unbelievable.
And the most frightening about this story is that there are hundreds or even thousands of captains out there with this kind of attitude... :(

[golfyankeesierra]

The F/O was an ex F16 pilot (wikipedia) (http://en.wikipedia.org/wiki/Airblue_Flight_202), rank of sqn ldr even, and he was intimidated (severely I might add) by the captain, who others consider to be a amiable man. HF nightmare!

[Bond'll Do]

Yes, BB...it takes time to change attitudes for CRM.

Arrogance = FAIL in any cockpit.

FACT! :ugh:

[The Ancient Geek]

The F/O was an ex F16 pilot (wikipedia) (http://en.wikipedia.org/wiki/Airblue_Flight_202), rank of sqn ldr


So we have a leader of men and an experienced pilot in the RH seat.
All it takes a captain with an insecure personality and the natural reaction will be to "put the FO in his place".

This was a surefire recipe for conflict and disaster.
They should never have been together.

[Basil]

I suspect that I'm the usual mix of hubris, arrogance, humility, respect, competence, incompetence. We are not supermen; just selected and trained humans.
I flew, as a B747 captain, with ex RAF Harrier and Red Arrows first officers including a Reds Leader. As an ex RAF truckie I was pretty impressed by these guy's history. They'd have been (and I hope now are) great captains to fly with; competent and confident and, therefore, relaxed.
However! There is only one captain and let's hope he runs a flight deck in which his FO may speak up and the old man (sailor's term for captain) is sensitive to concerns so voiced.

That's all a general comment - I've no idea what happened on that ill-fated flight deck.
p.s. Just in from pub - usual disclaimers :)

[aterpster]

There was quite a bit of discussion here shortly after that crash happened. I constructed the generous PANS-OPS circle-to-land area for Runway 12. It should have been a "piece of cake" for the captain unless he ran into obscurations and showers. Then, a missed approach would have been very easy compared to many airports.

Instead of turning toward the airport within the generous circle-to-land area they continued northwest for approximately 3 miles beyond the boundaries before they were in real trouble. And, with the first EPGWS warning, had the captain pulled full aft on his side stick, they would have almost certainly out-climbed the terrain.

[BOAC]

I find it strange that an F/O with his reported 'background' would be so 'intimidated' as to allow him to be killed. Either the quality of PAF pilots is suspect OR something does not ring true. I cannot envisage any situation where whatever the sullen silence/anger/despair/whatever he was experiencing would allow this. The one thing being on your own in a high performance aircraft teaches you is an instinct for self-preservation.

I am also confused by the reference to "The high rate of descend at very low altitude could not be arrested and the aircraft flew into the hill and was completely destroyed." for dawn.com as I thought it had been established that they were more or less level at impact. I assume Dawn means terrain closure rate - or do we have a new aspect to this crash?

[sleeper]

I find it strange that an F/O with his reported 'background' would be so 'intimidated' as to allow him to be killed.


Maybe that's just it. Coming from the airforce, he was indoctrinated with rank, especially in that region of the world. So when flying as a F/O, his captain outranked him and he obviously was not used to go against higher rank even though he had been a squadron leader.

In these countries the boss is always right.

[RoyHudd]

Hats off to the Peshawar authorities for a transparent report.

Sadly the CRM issue is a common one.....here a bullying,insecure captain and an able but relatively new first officer combined to crash a serviceable aircraft. Had the FO been allowed to speak up, and an accident then been avoided, the FO would have probably damaged his career prospects or even lost his job. A bad CRM culture stems from the Flight Director and Chief Pilot, who are the people in a position to change things.

In many cultures, CRM is not seen as an important or relevant issue, and the results of this bone-headedness are all to clear to see. (E.G. KAL's spate of crashes in the recent past)

[Capn Bloggs]

Interesting that a report into a fatal accident takes fewer than 40 pages
Could you please post a link to the report?

[BOAC]

As JH says, there is no 'report' for us and I suspect we will not see it. It appears to be 38 pages long. It was submitted to the government on 20/12.

There is not much from the History of PIA forum to add to the 'Dawn' item: note the number of GPWS warnings:eek: That's one every 3 seconds. Anyone explain a 'PBD based approach'?

"The report said the captain of the unfortunate flight violated the prescribed Circling Approach procedure for RWY-12 by descending below Minimum Descent Altitude (MDA) (i.e. 2,300 ft instead of maintaining 2,510 ft), losing visual contact with the airfield and instead resorting to fly the non-standard self-created PBD-based approach, thus transgressing out of the protected airspace of maximum of 4.3 NM into Margalla and finally colliding with the hills.

“The aircrew captain not only clearly violated the prescribed procedures for circling approach, but also did not at all adhere to Flight Crew Operating Manual (FCOM) procedures of displaying reaction and response to timely and continuous terrain and pull up warnings (21 times in 70 seconds)."

[Ten-miles final]

PBD is for sure Place/Bearing/Distance - an Airbus terminology for constructed way point (not in FMGS database) referenced to database way point. It means (to my understanding) circling approach was not conducted by timing as prescribed but in NAV mode.

[inflightrefueling]

About the sequence of events, the report said during initial climb, the captain tested the knowledge of the FO and used harsh words and snobbish tone, contrary to the company procedure/norms.

“The question/answer sessions, lecturing and advices by the mishap, the captain continued with intervals for about one hour after takeoff. After the intermittent humiliating sessions, the FO generally remained quiet, became under confidence, submissive and subsequently did not challenge the captain for any of his errors, breaches and violations.”

ICAO should set some standards for crew behavioural patterns and all member states' civil aviation authorities should seek these standards when it comes their carriers to employ cockpit and cabin crews. Surely and essentially, this process should be audited by the ICAO.

what a wonderful world..

[BOAC]

Ah - the 'going Boeing' brigade call that simply 'creating waypoints':p (CW, of course)

[Centaurus]

Had the FO been allowed to speak up, and an accident then been avoided,

I don't think it was a question of the F/O being allowed to speak up. From reading the summary it seemed he lacked the balls and was too scared to do anything. This is common in some cultures. Years ago in my company there was a similar incident but with a happy if somewhat dramatic ending. Captain was overbearing heavily built American. F/O was wiry no nonsense Australian.

Captain as PF descending at night into a South Pacific airport and set the altitude alerter to descend below the sector MSA when the rules stated stay at Sector MSA until inside a specific DME distance from the VOR.

F/O suggested correctly that Sector MSA was inviolate. Captain snarled at him telling him to shut up and continued to descend. F/O warned him once more and when the captain pressed on regardless, the F/O grabbed the cockpit crash axe and threatened to brain the captain unless he stopped the descent.

The captain wisely then took the F/O advice. The original concept of CRM I am sure did not envisage the crash axe as a cockpit resource. But it certainly worked, though. The so called "macho culture" exhibited by some pilots is sometimes an ethnic thing and sometimes a dreadful cultural affliction known as Loss of Face. To those types CRM is a meaningless term.

[Huck]

Got to love those captains that play twenty questions. Trying to mentor the F/O.

Don't mean sh!t if you can't fly the plane.....

[BOAC]

It looks as if the F/O may have been a belated entry for the Darwin award.:confused:

An interesting insight into PAF pilot quality for the IAF.

[jjeppson]

No matter what seat you are in, you don't just sit there while the other pilot tries to kill you! Where were these guys trained?

[BOAC]

Well, my entry for your competition is 'PAF' (see post #4)

[Airbubba]

F/O warned him once more and when the captain pressed on regardless, the F/O grabbed the cockpit crash axe and threatened to brain the captain unless he stopped the descent.

I'm sure this is one of those stories that starts, "Now, this is no s**t!";)

The Sky God days are pretty much over in America from what I can see. Now, the captain is more of a whipping boy, no matter what happens, it's his, her or its fault. Lord help you if you miss a signature or incorrect MEL reference in the logbook. Safety is a consideration but many decisions are made on the basis of CYA and how will it play at the hearing. If ATC offers you an intersection takeoff on a very long runway, you'd better set the brake and make sure you have data for that particular intersection even though you know you are legal (and safe) for an intersection with a shorter takeoff roll.

The report said at 0439:58 (70 seconds before the impact), first Enhanced Ground Proximity Warning System (EGPWS) warning of ‘terrain ahead’ started sounding meaning that the EGPWS worked exactly in the manner for which it was designed. It is added that the aircrew ignored several calls by the ATS (Air Traffic Services) controllers and EGPWS system warnings (21 times) related to approaching terrain and pull up.

Suicide, plain and simple, suicide...:eek:

[denlopviper]

Small question

the CVR overwrites itself every 30 minutes by design, so how would the investigation team know what the flight crew talked about in karachi or enroute.

also the nonstandard procedure that is the Circle to Land procedure is an approved procedure at OPRN which is followed quiet regularly

on the FMS, you dont input BBIAP or JIAP (these arnt even IATA codes, just local abbreviation for the airports) , you enter 4 letter ICAO codes ie OPKC for karachi and OPRN for islamabad. so that part is bulls**t as well

MDA for Cats A, B its 2410feet and for Cats C, D its 2510feet. the catagory the aircraft fits into depends on its appraoch speeds. either way the margallas are between 3500 to 4200 feet.

about China Southern and others not doing Circle to Land. the answer is very simple. the crew arnt allowed to fly a procedure at an airport they havnt recieved training for. if they had gotten sim training on circle to land at OPRN, they would have flown the appraoch.

whatever they are saying about the captain it from reputation. If he did indeed confuse the airports and the restricted areas, that comes down to fatigue and therefore was unfit to take the flight in the first place.

the FO was new and had about 100 to 150hours on the A320.

also they didnt mention who was the Pilot Flying and Pilot-Not-Flying. kind of relevant. captain should have been flying since the airfield was on the left side of the aircraft

high rate of descent?, yeah right. the aircraft hit the mountain in a nose high attitude with engines at high power. high rate of descent would only be possible if the aircraft was in a dive, or the aircraft was stalled. and knowing a bit the flight control system on the aircraft, you cant stall a A320. the aplha protection system kicks in before the airplane stalls.

half the report is incorrect.

plain and simple case of CFIT.

question which still hasnt been answered is why did they fly in a straight line for over 4 minutes without taking any action? from the point where you break off the ILS to start the circling procedure to the crash site is about 10NM. even if they were flying at 140kts, that makes just over 4 minutes of flying. for a guy whose been flying for 20 plus years and someone who just recent finished his line training, it doesnt make any sense..

[BOAC]

the CVR overwrites itself every 30 minutes by design, so how would the investigation team know what the flight crew talked about in karachi or enroute.

Modern CVRs run for much longer

also the nonstandard procedure that is the Circle to Land procedure is an approved procedure at OPRN which is followed quiet regularly

I think they refer to what he 'flew'?

whatever they are saying about the captain it from reputation. If he did indeed confuse the airports and the restricted areas, that comes down to fatigue and therefore was unfit to take the flight in the first place.

Based, I believe, on the CVR, not 'reputation?

[Airbubba]

the CVR overwrites itself every 30 minutes by design, so how would the investigation team know what the flight crew talked about in karachi or enroute.

It's a dirty little secret but many modern cockpit voice recorders log two hours or more of conversation. Also, with both analog and digital recording technologies, 'erased' portions of the recording can be, uh, 'recovered' it turns out.

The FAA and the NTSB had a field day with the extended cockpit chat of the ill-fated crew of a commuter plane crash in Buffalo, New York in 2009. Much of the conversation had nothing to do with operation of the aircraft but portions were later read at congressional hearings on pilot rest rules. If I knew I would be testifying before Congress, I might chose my final words more carefully. In the U.S., strict legal and contractual protections are supposed to ensure the privacy of CVR content but once an accident or reportable incident occurs, eveything on the recording seems to be fair game for the feds.

Many aircraft operating manuals have legacy boilerplate text about 30 minutes of recording, the erase button really works, no recording after the engines are shut down etc. Much of this stuff is no longer true from what I've been told by folks who should know.

Obviously, CVR legal protections vary internationally, I have no idea how things work in Pakistan.

[Machinbird]

The captain's behavior-confusion, failure to respond, etc could possibly be explained by a mild TIA event.
TIA=Transient ischemic attack.
Symptoms

Symptoms begin suddenly, last only a short time (from a few minutes to 1 - 2 hours), and go away completely. They may occur again at a later time.
The symptoms of TIA are the same as the symptoms of a stroke and include sudden:


Abnormal feeling of movement (vertigo (http://www.nlm.nih.gov/medlineplus/ency/article/003093.htm)) or dizziness
Change in alertness (sleepiness, less responsive, unconscious, or in a coma)
Changes in feeling, including touch, pain, temperature, pressure, hearing, and taste
Confusion (http://www.nlm.nih.gov/medlineplus/ency/article/003205.htm) or loss of memory
Difficulty swallowing
Difficulty writing or reading
Inability to recognize objects or people
Lack of control over the bladder or bowels
Lack of coordination (http://www.nlm.nih.gov/medlineplus/ency/article/003198.htm) and balance, clumsiness, or trouble walking
Muscle weakness of the face, arm, or leg (usually only on one side of the body)
Numbness (http://www.nlm.nih.gov/medlineplus/ency/article/003206.htm) or tingling (http://www.nlm.nih.gov/medlineplus/ency/article/003206.htm) on one side of the body
Personality, mood, or emotional changes
Problems with eyesight (double vision (http://www.nlm.nih.gov/medlineplus/ency/article/003029.htm), loss of all or part of vision)
Trouble speaking or understanding others who are speaking

Unlikely to see this in a young puppy, but this is a good reason to evaluate the other guy's performance, even if he is a senior, highly respected pilot. You will likely not observe the complete laundry list of symptoms, just a few.

If what he is doing doesn't make sense, you have to ask him WHY he is doing what he is doing. If the answer doesn't work, it is time to take action.

And for you grouchy guys, suck it up and answer the other guy's questions, he might have a good reason for asking.

[parabellum]

The way the report is written indicates, (to me), that the Captain was in some degree of anxiety state, sometimes a prelude to a panic attack. We shall never know.

[BOAC]

the Captain was in some degree of anxiety state - unfortunately according to the report the F/O was not:confused:

[maajam]

Have read the report.

It is chilling. 21 EGPWS alerts including F/O begging captain "Sir, pull up, Sir", three/four times and ending with "We are going down, Sir, we are go....".

Heading bug was rolled to the left but not engaged. Captain asks aloud in Urdu "Why is it not turning left"? F/O has no answer. When finally engaged, aircraft turned RIGHT (shortest distance). Bank angles of upto 54 degrees reached. Power was applied but not TOGA detent. There was a picth-up and then a pitch-down. The descent does sounds very odd. Report says descent rate of -3,000fpm was recorded.

No CVR or DFDR outputs appended but obviously report is drawing on them.

BEA and NTSB were accredited reps.

Stage set for disaster in the cruise when Capt. tests F/O's "technical" knowledge and then disparages and humiliates him for his poor answers. He goes into a shell but still has the courage to speak up when sensing imminent danger but not the courage to take over control and GA which he should have done assuming subtle incapacitation.

They were NOT visual at all times but informed ATC they were. When radar picked them up again and transmitted instructions to GA immediately, they had crashed.

Capt. had 26,000 hours on all types in PIA. Only 1,000 hours on 319/320/321. F/O had only about 300 hours on Airbus.

We may criticize report but this is the first one published in 64 years. All thanks to the High Court, the petitioner, families and media which kept the pressure on. So all in all a historic first.

[JammedStab]

Have read the report.

We may criticize report but this is the first one published in 64 years. All thanks to the High Court, the petitioner, families and media which kept the pressure on. So all in all a historic first.

So how did you get hold of it and how can we get hold of it?

Thanks

[maajam]

I got a hard copy and took notes on site while reading it so I hope most of my quotes are accurate. I think they are.

I was asked to return the hard copy but I hope I can put it up here for your analysis and opinion.

That is what safety is about. Sharing that information with experts.

After I finished reading it, my hands were shaking. I could not believe that a 26,000 hour captain could be so dumb and so unwilling to accept that he was headed towards disaster.

[JammedStab]

O.K. thanks, we are now awaiting your uploading of the report. If you encounter any difficulties, there are plenty of people on this site that can help you.

Thanks.

[maajam]

Have it on my HD now.

Please advise how I can post it here. Should I simply post the full 38 pages?

Merry Christmas.

[Machinbird]

Have it on my HD now.

Please advise how I can post it here. Should I simply post the full 38 pages?Best way to post such a document is to make it into a PDF file and host it on the web. Then post a link to it.

Is it officially released to the world? Don't want to step on anyone's toes.

PM if you need help.

[JammedStab]

Thanks Maajam. If anyone else has any suggestions on how to post it, could you please give some advice as he may not know how to make it into a PDF file. I don't think I know that.

[Machinbird]

Jammed and maajam, to make PDF documents, you need a PDF converter piece of software such as the full Acrobat or what I have: Nuance - PDF - Nuance PDF Converter provides everything you need to create, convert, edit, assemble, and securely share PDF files (http://www.nuance.com/for-business/by-product/pdf/index.htm)

Then it is a simple matter of assembling the document and publishing it. If necessary, I can convert for you-assuming receipt in the next 36 hrs. That was the point of the PM comment.

[Skittles]

If you have Office 2007, just open it in word and choose 'save as' - it will give you the option of saving it as a PDF.

[maajam]

Thank you, Sir. Let me try that.

I am generally not a novice when it comes to a computer but there is always a first time!

I would like to caution everyone that the print is very poor and I had a tough time reading it again on my HD.

It seems to be a photo-copy but a bad one at that.

[Redredrobin]

If it's a scanned or photocopy image of a document then it can't be fed into a word processing program like Word. There is a free utility called PDF Creator (Google that name to get the download) that will act like a printer on your computer and create a PDF file rather than a print when you send any document to print (cancel your normal attached printer and send it to PDF creator instead)

[maajam]

You are right. I could not get anything out of a right click. I will try your suggestion. Sorry for being so un-cool.

[BOAC]

From a public domain source, this link (http://shamimshaikh.files.wordpress.com/2011/12/ed-202-crash-report.pdf) takes you to the poor quality scan of the report. Some diagrams are not readable, but the reasons for the crash can be easily determined. It is not comforting reading.

[maajam]

Thank you for saving me further embarrassment.

[JammedStab]

No problem Maajam. We appreciate your effort. Perhaps you could search for some earlier Pakistani reports if you have the proper connection. It would be a great help.

Thanks again.

P.S. Some said earlier..."Is it officially released to the world? Don't want to step on anyone's toes". I don't think we should worry one bit about that as some countries seem to rarely if ever release reports like this and they should be released in the name of furthering aviation safety regardless of how many toes are stepped on.

[aterpster]

BOAC:

From a public domain source, this link (http://shamimshaikh.files.wordpress.com/2011/12/ed-202-crash-report.pdf) takes you to the poor quality scan of the report. Some diagrams are not readable, but the reasons for the crash can be easily determined. It is not comforting reading.

Poor quality as to diagrams, but certainly adequate as to text.

The circling area and the crash site location appears to be almost exactly what we went through here just after the crash.

My plotted position of the crash site differed 325 feet from the coordinates in the report. It is dramatic to see how far they strayed beyond the PANS-OPS circle to land protected area. As they approached the crash site no one was in control of that airplane.

I find it interesting that one of the recommendations of the report is the establishment of an instrument approach to Runway 12 if possible. As I demonstrated last year the only barrier to an RNAV IAP is political, not terrain. Further, unless the VOR station has performance issues, a VOR/DME approach is also feasible. Finally, unless the back course has issues, a BC/DME approach is also feasible.

[aterpster]

This is the long thread we had here at the time of the accident:

http://www.pprune.org/rumours-news/422401-airblue-down-near-islamabad.html

[maajam]

I don't think there will be an ILS on 12 anytime soon. The new airport about 30 miles to the west should be in service in, I think, in 2012/3, and it is supposed to be world class with dual runways and all the works.

Yet this could have been done many years earlier at minimal cost since many aid donor's would have been happy to gives us a grant to finance the equipment and have their contribution acknowledged.

The pilot kept asking for a right-hand downwind even though he should have known that it is not available since that would mean flying over the heavily-populated twin city of Rawalpindi.

[maajam]

Sir,

My information is that reports were always prepared even in the case of incidents. They were, for one reason or the other -- probably related to fear of litigation -- were never published.

With the judiciary hyper-active these days, once a petition was filed in two High Courts and accepted for hearing, it was only a matter of time before the authorities would wilt.

I am hopeful that this publication will open up a new era of transparency in the country in the field of civil aviation -- hitherto very much a sealed black-box.

[JammedStab]

Thanks Majaam.

If you do have some contacts and somehow come across a report. Please post it. Until then, happy flying.

[maajam]

May I ask those of you who have read the report to comment on it for my edification?

Now we know what.

What about "why"? Why did the captain do everything wrong, violate all procedures with such impunity and ignore the warnings from the EGPWS?

Over-confidence? Complacency? Arrogance? Subtle incapacitation?

Thank you in advance.

[BOAC]

I cannot begin to explain the Captain's performance but it does appear that possibly being ex PIA there was some perceived 'status' issue where he did not need any help thank you.

It is the F/O's behaviour I find very strange - to allow yourself to be driven into a hill without attempting to stop it. Are all PAF pilots that 'weak'? I am pretty sure that no amount of derision, whiplashing, abuse, shouting at etc etc from a Captain would cause a British mil pilot to sit there and do very little. As I said, the IAF must be rubbing their hands with glee.

[Centaurus]

It is the F/O's behaviour I find very strange

I understand your point. The vulgar amongst us call it lack of balls. Others recognise it as an affliction called "ethnic culture" and often - as in this typically tragic case - anathema to good airmanship and flight safety. The statu quo will never change.

[maajam]

Well, Sirs, the "pairing" was awful. One with 26,000 hours and very senior, well known and respected, having served a life-time in PIA, while the other, a young-buck, PAF-background or not. A steep gradient in rank -- and they should not have flown together. That would be Air Blue's failing.

Cultural factors? I suppose it played a part. Respect for and deference to elders, which CRM training was not able to overcome.

But is the culture issue only an "affliction" of eastern cultures?

Despite facing the prospect of imminent death, the F/O remained submissive. He did speak up, many times, and I would imagine with increased urgency in his voice as they got closer to the hills. Yet he did not take control.

To my mind, a needless and eminently avoidable tragedy which snuffed out the lives of all souls on board.

[clear3]

Centaurus, you are correct! Those guys are literally bred not to question the skipper. Crazy in our world (western) but thats how it is over there.

In that general area of the world.......CRM= Captain Rules Motherf@#@#r!

Yes, im sure there will be somebody telling me that they practice some sort of CRM..........BEEN THERE DONE THAT....read above!

A published report is half way to solving their problem! Ill pay that, but how many more before they get bloody serious about it?

[BOAC]

maajam- you are correct, and in fact the thread title is incorrect as the crash was caused by both pilots, one by commission and the other by omission. In a normal world the reason for having two pilots should be to prevent just this event.

There would not appear to be any reason why the two experience levels should not 'mix' ok - if any protection is given to a 'newish' F/O it is normally NOT to roster him/her with a NEW captain. I do not see failing of AirBlue here, but of the apparent whole system in Pakistan's aviation, civil and military.

[Dengue_Dude]

Having flown for a year on contract with Biman Bangladesh a few years ago, sadly nothing I've read here is a surprise.

The Culture of the sub continent and CRM are often mutually exclusive. Never did I see a greater need for CRM by the majority of the captains, never have I seen it resisted so much.

Until one or other of these dilemmas is resolved, these type of accidents are going to continue. Sadly, until those first officers who've been trained within a culture of CRM reach 'maturity' and the LH seat, then resist the 'Might-is-Right' culture (having now 'got there'), I don't realistically envisage a change.

Such a crying shame.

[maajam]

BOAC,

Sir, I would have thought pairing with a more mature F/O who may have learnt some real-life CRM lesssons himself may have been more prudent. Not this young chap with less than 300 hours in-type. In his case, he should be been flying with a less experienced, younger captain, if you see what I mean. It would have made for better "vibrations".

F-16's in the PAF would not teach him CRM. So he must have taken one course during gaining proficiency in-type and who knows how much he absorbed.

Put someone old enough to be his father next to him with more years of flying experience than his age (34), and you have a very intimidated puppy. Not to mention the drubbing he got in the cruise.

And fate intervened. Capt. Choudhry was only rostered to fly the night before.

I am not making excuses for the F/O and, yes, BOTH, pilots were to blame, maybe the F/O more than the captain since the latter was confused and had lost SA. The F/O had not and knew where they were heading. "Terrain is coming, Sir".

The recent Air India Express accident at Mangalore was another example. That was a good report. Late descent meant they were coming down like a rocket. The F/O called "unstabilized" and then "go around" but that may have been more of a question. When they floated, he called "go around" again.

I could have some of the sequence wrong. Read the report some time ago.

In that case, deference to a "foreign" pilot?! They hate them because they feel they are taking away jobs from the natives. But complexes, also culturally ingrained, are not easily overcome. The captain was not a Brit., their former colonial masters. But he was "white".

[before landing check list]

I think we can all agree that adding the ILS on 12 will not solve this type of problem.

[M.Mouse]

The inference that an experienced captain should not fly with an inexperienced FO is a false premise.

CRM first came to prominence when several accidents occurred and were caused by the resources (crew) and their skills being poorly managed and having a direct bearing, if not sole cause, on the ensuing accident.

One notable example was the DC10(?) which flew into the ground (Florida I think) while perfectly serviceable because all three flight crew were pre-occupied with what turned out to be a failure of one of the three landing gear green lamp indicators. Nobody was flying the aircraft.

In more recent times in the UK the British Midland B737 crash at East Midlands Airport gave us all some strong lessons in how the CRM aspects of the flight could have been handled better. I know that in BA it led some some changes in emphasis during recurrent training.

My point is that until the national authorities force airlines like Air Blue to design and implement initial and recurrent CRM training courses for all their pilots only then will avoidable accidents like the one in question be prevented.

The first CRM course I attended was the initial BA offering. It was residential and lasted three days. There was opposition but the flight deck culture slowly and surely changed for the better. The days where BOAC captains only spoke to the junior first officer through the flight engineer or senior first officer were finally laid to rest.

In the early 1990s I recall one former BA cadet, who had not long graduated and completed his line training, who took control from an experienced captain and flew a go-around when he was unhappy with the what he judged to be a flare at too great a height. As it happens he was wrong and he was suitably de-briefed on the incident. But which would you prefer a co-pilot sufficiently well trained and confident enough to be aware that he has a responsibility and duty to safeguard the safety of a flight, physically intervening if he has to, or one like the hapless Air Blue co-pilot? In the BA incident what he did may have been an error of judgement caused by great inexperience but what he did was not actually dangerous. The alternative, in a situation like the Air Blue crash, is often fatal.

Of course it all costs money so please don't hold your breath waiting.

[Airbubba]

One notable example was the DC10(?) which flew into the ground (Florida I think) while perfectly serviceable because all three flight crew were pre-occupied with what turned out to be a failure of one of the three landing gear green lamp indicators. Nobody was flying the aircraft.

It was actually an L1011 and it flew into the water of the Everglades:

Eastern Air Lines Flight 401 - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Eastern_Air_Lines_Flight_401)

You are right, the only aircraft malfunction was burned out filaments in a landing gear indicator.

"I admit the human element seems to have failed us here." - General Buck Turgidson in Dr. Strangelove (1964)

[Sqwak7700]

There is mention of the FO's lack of assertiveness in taking command of the situation knowing their treacherous predicament. But you have to wonder, had that FO been assertive and taken over, what would be the result? The kind of airline that maintains the employment of such a Captain sounds to me as and airline that would not investigate and would terminate the career of someone questioning someone of higher rank. That needs to be addressed as it is a very big factor in this accident. All the CRM courses in the world will not fix a lack of safety culture.

Not that it would affect my reaction if in the same situation. I would rather be fired than dead. It just makes you wonder what it takes to move those priorities, it seems like certain regions of the world suffer greatly from this lack of prioritization. This accident reminds me of the GFA A320 that flew right into the gulf. The FO even said a little prayer before they hit the ground, the CA didn't even know what hit them (or more appropriately, what he hit).

[M.Mouse]

All the CRM courses in the world will not fix a lack of safety culture.


Agreed.

When I said that the relevant authorities would need to force the implentation of CRM training it would mean that the authorities had to recognise that they had a serious safety culture issue in the first place.

I believe modern CRM developed from NASA research into the causes of air transport accidents. The research identified the human error aspects of the majority of air crashes as failures of interpersonal communications, decision making, and leadership.

[Skittles]

I think something that people are perhaps failing to take into account when laying blame on the F/O is that the action to be taken was hardly straight forward.

Essentially, the F/O was convinced that the aircraft was in trouble. The Captain was convinced that the aircraft wasn't in trouble, and that doing what the F/O wanted to do was the incorrect form of action.

Both of you are confident you are right. Are you going to let go of the yolk?

[aterpster]

before landing checklist:

I think we can all agree that adding the ILS on 12 will not solve this type of problem.

Which problem? The captain's rants or the crash?

[denlopviper]

for the record i never defended the captain.

"There is mention of the FO's lack of assertiveness in taking command of the situation knowing their treacherous predicament. But you have to wonder, had that FO been assertive and taken over, what would be the result? The kind of airline that maintains the employment of such a Captain sounds to me as and airline that would not investigate and would terminate the career of someone questioning someone of higher rank. That needs to be addressed as it is a very big factor in this accident. All the CRM courses in the world will not fix a lack of safety culture."

you have no idea how true that is here.

one factor which everyone is overlooking is the intense rivalry between civilian pilots and ex-military. civilians in command will do anything to make life hard for ex mil in the right seat for the sole reason the ex military pilots are the preferred pilots in the Pakistani market.

you are never allowed to fly a circuit south side of the field at OPRN. you get way too close to the GHQ and the ministry of defense. the GHQ is 2.7 nautical miles from the threshold of 12,Ministry of Defense is 2NM from the threshold, PAF sector command is also less than 1.6NM away and all of them are south of the field and inside the Prohibited area shown on the ILS-DME 30 plate OP(P)254. yes they are that that close.

so the captain asking for for a right downwind on runway 12, is something he knew he wouldnt get.

[maajam]

Yes, it is pertinent to ask what would have happened to that F/O if he had pushed that "side-stick priority" button in front of him and announce firmly: "MY aeroplane".

Well, they would all be alive to begin with. The Capt. would have thrown his considerable weight about and charge the F/O with mutiny and insubordination but given the mood of the judiciary and the vibrancy of the Pakistani media, the story would have got out. The F/O would have leaked it himself if he felt threatened and he would have petitioned the High Court/Supreme Court if his services had been terminated.

I would like to think the ending would have been a good one, a wake-up call to other god-like captains with all F/O's around the world feeling a new sense of empowerment!

I accept all the valuable points made about CRM by the writers above. Sadly, this young fellow did not have it in him (youth, inexperience, humbled and over-whelmned) even as he knew, as he surely did by his words, that his inaction would lead to his end.

But I take comfort from the fact that the good pilots out-weigh the bad by an overwelmning margin which helps make commercial flying as safe as it is -- despite the recent spate of accidents about which I have read here -- analysed with great clarity and insight.

This forum should be required reading for every airline!

[mtwittm]

Hi All

I found a video of a PIA 747 takeoff from Karachi operated by Captain Pervez from the ill fated Airblue flight. Below is the link, is there proper CRM taking place in the cockpit?

I am not a professional pilot, just a private pilot. It is scary reading about this CRM issue and the human factors / egos involved. Also if a junior pilot wants to take away control from the captain, does he just grab the control stick away forcibly?
PIA Boeing 747 Takeoff from Lahore Airport - YouTube

[maajam]

denlopviper,

Saying there is a lack of a safety culture is a bit extreme. PIA and the other private airlines operating in Pakistan (with more to come, we are told), don't lack a safety culture. It is not a glaring issue.

I believe their procedures are checked out and cleared by safety audits all the time. If there are concerns, they will be warned and then they will be banned from European and US airspace (the former has already happened and I must confess to hanging my head in shame where a once-great airline, the best in Asia, had to suffer such indignity).

Times have changed. There is too much transparency that is now forced upon you -- via the inter-net and/or the media. You cannot hide. This is not some bush operation out of Africa that you can keep hidden from the world and still expect to fly into their airspace and airports.

By all accounts, Air Blue was a sound operation with only a couple of incidents such as a tail-scrape, until the "Margalla Tragedy".

I heard that after that, they dismissed all their ex-PIA pilots over the age of 60 whom they had re-employed (since the new retirement age was 65). That must surely be the dummest thing they could have done. I am not aware of any robust correlation between age and accidents. Robust, that is. Not a spurious correlation that fails a "t-test".

Asking for a right-hand downwind was indeed very strange. Surely Capt Choudhry knew that was not available because of the twin city of Rawalpindi but also because, as you have reminded us, the great gods of GHQ!

Imagine, the sounds of a noisy jet flying over their hallowed headquarters when they are busy THINKING.

Anyway, let this not degenerate into a civilian-versus-military conflict (although you hear about that even in the US and UK0.

I don't know where the airlines get the majority of their pilots from but I would not be surprised if it is still from the various flying schools in the country, as well as PIA's own Flight Academy -- and not from the PAF.

But I stand to be corrected.

[maajam]

I have seen the vidoe above. We cannot tell about CRM and check-lists since the audio is not very clear. But it does show a commander that is supremely confident.

You would be if you had been flying the 747 for 15 years and knew her like tha back of your hand.

[RoyHudd]

CRM is a major issue here, it seems. But neither the Captain nor the FO were competent enough to read the FMA, which immediately informs the status in NAV or HDG. The Captain seemed too overloaded to pull HDG, and the a/c stayed in NAV, hence heading towards high ground.

Do Air Blue SOP's demand FMA call outs by PF, with "Check" from PNF when checked? If not, then SOP's are partly to blame. If so, then the pair managed to ignore SOP's and drive the a/c towards the Margalla Hills. Other issues, such as the a/c turning the shortest way when HDG was eventually pulled, indicate that the CM1 was not competent on type, and the CM2 was not monitoring correctly. (Or scared to inform his Captain that he had made another mistake)

A sad and unnecessary crash, caused by 2 pilots who were simply not competent as a team.

[denlopviper]

denlopviper,

Saying there is a lack of a safety culture is a bit extreme. PIA and the other private airlines operating in Pakistan (with more to come, we are told), don't lack a safety culture. It is not a glaring issue.

i fly in pakistan and trainined pilots for Etihad (EY). i didnt say there is a lack of safety culture. i said there is intense rivalry amongst civil and military pilots. i am caught between the war so i know. each group feels threatened by the other.

Times have changed. There is too much transparency that is now forced upon you -- via the inter-net and/or the media. You cannot hide. This is not some bush operation out of Africa that you can keep hidden from the world and still expect to fly into their airspace and airports.

By all accounts, Air Blue was a sound operation with only a couple of incidents such as a tail-scrape, until the "Margalla Tragedy".

im guessing your currently not in the field?

what transparencies? if you mean this report getting published, i already said that all the reports are available from all the incidents. you just need to find them.

I heard that after that, they dismissed all their ex-PIA pilots over the age of 60 whom they had re-employed (since the new retirement age was 65). That must surely be the dummest thing they could have done. I am not aware of any robust correlation between age and accidents. Robust, that is. Not a spurious correlation that fails a "t-test".

there were only a few 6 or 7 i think.


Asking for a right-hand downwind was indeed very strange. Surely Capt Choudhry knew that was not available because of the twin city of Rawalpindi but also because, as you have reminded us, the great gods of GHQ!

Imagine, the sounds of a noisy jet flying over their hallowed headquarters when they are busy THINKING.

Anyway, let this not degenerate into a civilian-versus-military conflict (although you hear about that even in the US and UK).

one of those Gods as your proclaimed them just happens to my dad. there are no fly zones and prohibited areas around most if not all sensitive installations around the around, not just in pakistan. have you seen the number of prohibited and restricted areas in the UAE?


I don't know where the airlines get the majority of their pilots from but I would not be surprised if it is still from the various flying schools in the country, as well as PIA's own Flight Academy -- and not from the PAF.

as far as PIA goes. they have inducted about 300 pilots since 2005 till today. before that last last regular induction was in the mid or early 90s. thats over 10 years without a single cadet pilot course.

for PIA about 25 to 30% ex military

Airblue and Shaheen, sorry to disapppoint but 80% plus of their crew are ex military.

Bhoja and Indus which are opening up, and average of 60 to 70% of their crews are ex military.

as far as flight schools go, PIA training academy, Rawalpindi flying club, Peshawer flying club, Hybrid aviation, Lahore flying club and Multan flying club have ex military chief flight instructors. that only leaves out Schon who i know have ex military instructors.

list goes on...


PS. i dont have any grudges against military pilots, i have a huge respect for the guys.

[maajam]

RoyHudd,

Sir, you make some very valid points. The fact that the Capt. did not know why the a/c was not turning left and the F/O did not know either gave me the willies too.

Just disconnect the damn AP and fly the aircraft yourself! You can figure it out later.

Denlopviper,

Thank you for all the clarifications, Sir.

You think 6-7 top pilots in Air Blue dismissed because of their age is "small"? That was the cream of the crop.

Anyway, they are happy now flying elsewhere and getting five times the pay.

I know about restricted zones. I was wondering why the Capt. did not.

I am sorry to hear about the tension between military and civilian pilots in Pakistan. Whatever the merits of the case, the cockpit of an airliner is not the place to carry your resentments into.

Whether the Capt. being harsh with the F/O was also driven by that tension, I do not know. Perhaps it was? And look what it resulted in.

Was the PIA Academy, once the best in Asia as was the airline, shut down because someone decided that the in-take shall be from the forces? No marks for anyone figuring out who would have ordered that in Pakistan!

Finally, I KNOW that reports have always been prepared even in the case of "incidents". I only made the point that given the hyper-active state of the courts and the media, there will be no secrets anymore. This report, whatever its limitations, is a huge breakthrough and marks a very important and significant day for transparency and openness, something that we have been denied for 64 years.

I hope this will extend to other areas as well. There are too many secrets in Pakistan and too much obfuscation and untruths floating about and a profusion of conspiracy theories. The former feeds off the latter.

Yesterday they celebrated the FOURTH death anniversary of Benazir Bhutto. There is still no report on who murdered her so brutally. How astonishing is that?

Of course 80% of the pilots at Shaheen are ex-military. It is run by the military!

[Centaurus]

yes, BOTH, pilots were to blame, maybe the F/O more than the captain

You must be joking! The captain makes a monumental cock-up in almost every aspect of the flight and you say the F/O is maybe more to blame than the idiot of a captain? Methinks you have your wires crossed somewhere.:ugh:

[maajam]

Ultimately, the responsibility for the safe conduct of the flight rests with the captain. I know that.

That is why he is paid so well and wears those four gold stripes and a star on his sleeves and has scrambled eggs on his cap.

In this case, I agree the Captain lost it. He did not even know how to use the Heading Selector and may have thought he was flying an analog-style 747 (which he did for almost half his entire career).

However, as someone above said, which made me pause and think, the ONLY one in that cockpit who KNEW what was happening and where they were headed and what would happen if they did not IMMEDIATELY take action, was the co-pilot.

Yet he sat there. Although he warned the Captain several times of impending doom, he did nothing. I don't know what goes into a CRM course but I would assume that it says something to the effect that if the Captain is non-responsive and is headed towards crashing the damn aeroplane, you assume incapacitation and take over.

He did not do that, for all the reasons adduced in the report and here, and got everyone, including himself, killed.

He bears significant responsibility too. But, as we all know, ultimately the responsibility lies with the person in the LHS. But that does not absolve the person in the RHS of blame.

The Captain's son is planning to lodge a protest in the court. I feel his pain. He says his father is not able to defend himself. In CFIT cases, they usually are not.

[aterpster]

Centaurus:

You must be joking! The captain makes a monumental cock-up in almost every aspect of the flight and you say the F/O is maybe more to blame than the idiot of a captain? Methinks you have your wires crossed somewhere.

The F/O knew they were headed for a crash into terrain. The captain apparently did not. So, under the doctrine of "the last clear chance" to avoid an accident, the F/O failed that requirement.

To conclude that makes the F/O more cupable, than a captain who was out of control, is not unreasonable.

[BOAC]

in fact the thread title is incorrect as the crash was caused by both pilots, one by commission and the other by omission. You can cut this both ways.

IF the Captain had not done x,y,z then............

IF the F/O had been decisive and taken control if necessary..................

Let's not confuse the lack of action by the F/O with any notion of 'warm/fluffy CRM'. This is NOT CRM. This is survival. This is acting as the second i/c when the first is patently 'not there'. It was either 'loss of face' by forcing control of the a/c away from the Captain or loss of body and soul along with everyone else by not so doing - what would the 'normal' person choose? At worst, suffer ignominy at the hands of the 'institution' - but live - and perhaps have to find another job OR be driven into the face of a hill at 200mph+?

[denlopviper]

Denlopviper,

Thank you for all the clarifications, Sir.

You think 6-7 top pilots in Air Blue dismissed because of their age is "small"? That was the cream of the crop.

Anyway, they are happy now flying elsewhere and getting five times the pay.


i was a flight instructor who was getting twice the pay of Airblue's FOs. big deal. the statement that they were the cream is completely illogical. tens of thousands of hours yes, on something as advanced as an A320, NO. simple fact is they would require the same training on the aircraft a a guy with 200 hours would.

yes they have abundant experience and there is not substitute. but in things like the A320, you dont fly, you manage the systems. and its way more easier to understand those systems for someone whos young. this is a general statement so hold your fire guys :p

time and again we have seen accident when the crew didnt fully understand how the systems on their aircraft worked.


I am sorry to hear about the tension between military and civilian pilots in Pakistan. Whatever the merits of the case, the cockpit of an airliner is not the place to carry your resentments into.

Whether the Capt. being harsh with the F/O was also driven by that tension, I do not know. Perhaps it was? And look what it resulted in.

this is something which isnt going to go away that easy. this is something that is usually kept outside the cockpit.


Finally, I KNOW that reports have always been prepared even in the case of "incidents". I only made the point that given the hyper-active state of the courts and the media, there will be no secrets anymore. This report, whatever its limitations, is a huge breakthrough and marks a very important and significant day for transparency and openness, something that we have been denied for 64 years.

maybe for you, but since we all already had access to previous reports, its not a big deal.

I hope this will extend to other areas as well. There are too many secrets in Pakistan and too much obfuscation and untruths floating about and a profusion of conspiracy theories. The former feeds off the latter.

Yesterday they celebrated the FOURTH death anniversary of Benazir Bhutto. There is still no report on who murdered her so brutally. How astonishing is that?

the world wouldnt be fun without conspiracy theories. for the BB case, we all think her husband did it, and yes im being serious.


Of course 80% of the pilots at Shaheen are ex-military. It is run by the military!

you been out of the country too long lol. Shaheen got privatized a long time ago. it is a pure civilian airline with no backing or interference from the MoD. yet still they prefer ex mil.

SAPS (shaheen airport services) which is now a separate entity is the one backed by PAF

even if you say that about shaheen, what about the 3 other airlines?


something which i recently found out about the FO.

he resigned his commission because he didnt agree with the operation in the tribal areas saying "i am not going to bomb my own people". so the notion that he didnt have balls is not really justified.

[maajam]

I was only speculating that CRM would teach that. I have not attended a CRM course to know its contents. But I would imagine you are taught to work together and, most importantly, speak up irrespective of rank in case the other guy/girl is doing something dangerous and if they don't respond despite several interventions, you must assume he/she has "lost it" and take over the controls.

[BOAC]

You are correct, and 'assertiveness' is what is encouraged - and what was missing. In most UK operations, 'three challenges' not heeded is sufficient reason to take control. Whilst it is not 'CRM' it has become bundled together with it.

[misd-agin]

It doesn't take a lot of 'system management' to turn the autopilot off and make the plane do what YOU want it to do.

It doesn't take a lot of situation awareness to react to "terrain, terrain" or "PULL UP!" Turning the heading bug is NOT the correct response.

I tell new guys - "automation is your friend, until it isn't."

[denlopviper]

yup your right.

"terrain, pull up" is something you react to without thinking.

well the report does mention the 54 degree bank and erratic pitch changes, which tells me he was flying and not the autopilot. at the same time they say the AP was engaged. doesnt the AP disconnect when there is stick input on the A320?

hmm doesnt the A320 come with an "overbank" alert or something like that? 54 degree isnt small. there is no mention of any alerts relating to bank

[Ten-miles final]

Autopilot disengages when pilot pushes on the sidestick harder than a certain threshold, furthermore in normal law with all protections available the AP will disconnect if bank angle is greater than 45.
Both flight directors are removed when the aircraft bank angle exceeds 45.
(Almost quote from FCOM). So bank angle of 54 may only be achieved without both AP and FD.

[maajam]

there is no contradiction. If you read the report again, after he finally pulled the heading knob and the plane turned RIGHT (shortest distance since his heading bug had been rotated to 086) the AP was turned off and then you got those rather wild changes in bank and pitch.


I think he even climbed for a while and then for no reason descended. Or at least that is what came from the DFDR.

I don't care for quotations only from the CVR/DFDR. The whole read-out should be there from take-off to impact in an annexure with a time-line. Furthermore, there are no ATC tapes which should also be in the Annexure. Since ATC is Air Force, I hope they are not trying to cover that part up. That would be a serious regression and raise doubts about other parts of the report. What a blow that would be.

Interestingly, there are people in Pakistan absolutely convinced even now that this is all a cover-up and that we will find out the real bomb-shell soon. They say there were some strange souls at the crash site before the rescue workers got there. Whoever they may be, what has that to do with the cause of the accident?

[Ten-miles final]

[16 seconds prior to impact the aircraft showed a 30 degrees bank angle to the left and 15 degrees nose up attitude, that was decreasing. 10 seconds before impact the aircraft peaked at 3110 feet and began to descend again until impact.]

Report is released. It also includes quotations from ATC both by air and land line.

[maajam]

yes, Sir, I remember that. Very strange late movements.

Panicked?

I meant the full read-out. It is normal and expected that it should be in an appendix with a time-line and any communications super-imposed.

I would also like to hear, with respect for the departed, the dressing-down the Capt. gave the F/O in his question-answer session in the cruise which evidently caused the latter such anguish.

The ATC part is also fragmented and selective. Maybe there is nothing there of interest but the tapes should be there in full.

I note, on reflection, that the 45 degree off-set heading at MAP for 30 is a timing manouver of 35 seconds including the turn which takes you out 1.4 nautical miles at 180 knots and well within "protected" airspace (if my memory serves me).

There is no indication on the CVR that clocks were pushed and confirmed "both sides". That should have been loud and clear.

[mtwittm]

Hi Majaam - are you a pilot? Did you fly in Pakistan?

[maajam]

Sir, or maybe, Madam?

How is this relevant to this dicussion which I am enjoying and learning from people far more expert that me?

We are all here with screen names (but valid e-mail's since we cannot register otherwise) protecting our privacy. People here do not want even their location on this planet known. "north south, everywhere, and anywhere"! Or something like that.

Please accept me for what I can contribute to this discussion, even if it is very little.

Let me just say I am interested in this accident and celebrate the day that Pakistan has published an accident report, however imperfect it may be, after 64 years of silence, thanks to the courts and the media.

It is late and even I, behind a screename, must sleep.

Good night.

[Reinhardt]

I would also like to hear, with respect for the departed, the dressing-down the Capt. gave the F/O in his question-answer session in the cruise which evidently caused the latter such anguish.

Both pilots were experienced, but in a different way. The F16 Sqn Ld was obviously beginning to build his experience in airlines, the moment you still have to work yourself a little bit to be 100% familiar with the new job (I know, I was there) Then quite rapidly you overcome this and you realise this new position isn't very...challenging (sorry, guys) but the first couple of months, well you don't feel so great.
Now from the left sear and the CRM factor: sometimes you have to do with captains who spent their life intercepting localisers, after a training which they paid for somewhere in the States, and those individuals resent having to share the cockpit with something undoubtedly smarter, feel the need to make life miserable for this F/O coming from another world they have no idea about... (and yes, I was there also, at the receiving end)
They know they have to take advantage of their superiority now as it will be short-lived, and within one year or two the guy in the right seat will be performing better than they have been in the past 20 or 30 years (and in their case too much experience might be counterproductive, as they have been doing the same thing for so many years..)
so yes, a very small minority of those people are bullying ex-fighter pilots a little bit too much (during the first year, after that it's too late for them, until they get a new joiner again)
And all that can make a very, very silent cockpit (because you aren't going to start to challenge back you Captain, aren't you ?) and that's not good in some situations, as we all know...

[denlopviper]

i already mentioned that i trained out of OPRN and fly in the middle east and pakistan based out of karachi and islamabad.

no one asked you where you are right now or your exact background. it was a general question as to have you ever flown in pakistan and are you a pilot.

you talk about culture of secrecy in pakistan which you want removed yet you demonstrate that exact same thing.

on that note, as a pilot i can simply say whatever the result of the investigations are should be kept to only the people who are concerned ie the aviation community. the reasons are easier for the aviation to community to deal with in the first place. you go try to tell a family that their father killed 152 people? the blame game is already in high gear here isnt it.

yes the crew were responsible, but in the name of transparency, its their families who will suffer.

oh well. its already done and their families are fighting to save the reputation of the crew.

lets see how that goes.

[Centaurus]

you must assume he/she has "lost it" and take over the controls.

It is not quite as easy as that. It is one thing to calmly take over control if the captain is incapacitated. An inexperienced F/O may run into trouble if he lacks the initiative and skill to rescue the aircraft. Although nominally second in command, many recently graduated cadet first officers lack the ability to become the instant captain with no one to guide them.

It is an entirely different situation if the captain is reckless and intent on breaking the rules of good airmanship and in so doing risking lives. While there is no shortage of well-meaning advice on what to say to that sort of captain, I have yet to see in company standard operating procedures any firm directions on the physical method to be employed by a first officer if the captain refuses to listen to reason.

If the problem occurs on final approach to land and the captain is the press on regardless type of personality, then an unstable approach is one result. Short of hitting the offending captain over the head as a precursor to taking control, the other thing that is easier and less dramatic is for the first officer to simply select the landing gear lever to up at the same time saying aloud "GO AROUND CAPTAIN" That fixes the problem real quick until the next approach of course when tempers will by now be frayed. But cross that bridge when you come to it :ok:

[Ten-miles final]

maajam
I note, on reflection, that the 45 degree off-set heading at MAP for 30 is a timing manouver of 35 seconds including the turn which takes you out 1.4 nautical miles at 180 knots and well within "protected" airspace (if my memory serves me).
There is no indication on the CVR that clocks were pushed and confirmed "both sides". That should have been loud and clear.
That's right, report stated on this stage maneuver was done in NAV mode, not HDG as prescribed. Furthermore, CF, the waypoint on final derived from FMGS (and used as referenced for building other PBD waypoints for NAV mode) was located on extended runway centerline 5 NM from threshold thus inherently bringing aircraft outside of protected airspace for circling approach.

[maajam]

Sir,

When a crew is implicated as in this case, the families always suffer and the immediate family suffer the most. This is not country-specific. It happens everywhere.

We lament that the dead cannot defend themselves. If you fly like this, you will be very dead and take a lot of people with you.

"Blame-game"?

Is there a dispute as to who is to blame? As far as I can gather, blame is being apportioned where blame is due. No one is challenging the findings of the report except a few individuals that feel that calling it "pilot error" is simplistic and a cop-out, or, in the case of the conspiracy-minded (which are in plentiful supply), a "cover-up" of darker forces at play. What those might be, I have no idea -- and neither do they.

Aviation matters only to be left to aviators? Excuse me?

Everone can and should be involved and be free to speak their mind. The Cabinet, National Assembly, Courts, Media and so on. They may not be terribly well-versed on the subject of commercial aviation and flight safety but they have the right to ask questions and get answers with the goal of making the system safer.

That is why I am here even if I am not a current jet-jock flying out of OPRN. I am here to learn from people obviously far more able than I, and to ask why, given the most sophisticated systems known to man at your finger-tips, and with all that training and all that experience, how and why this accident could happen.

Have a safe flight, Sir.

[maajam]

Centaurus and Ten-Miles, thanks for the elucidation.

I thought (or read somewhere) that subtle incapicitation is taught in simulators.

So, I am confused. Either it is a well-defined set of contingent actions or it is a grey area which SOP's don't address in specific detail.

Ten-Miles,

Sir, I understand the CF way-point. However, please explain to me these mysterious PBD way-points that he asked his F/O to enter (contrary to approved procedures) into the FMGS.

[mtwittm]

Hi Maajam

You sound a wee bit like this chap Mekal from link below not sure though. I just wanted to know if you were a Pilot, because you seem to be flogging this issue to death as if you are fishing for information.

Maybe airplanes are getting much too sophisticated and automated for human beings to handle.

http://www.pprune.org/rumours-news/422401-airblue-down-near-islamabad-5.html

[M.Mouse]

reinhardt, if you believe that former fighter pilots are smarter than civilian pilots then I would suggest that view is part of the problem, apart from the fact it is patently wrong.

I have flown with all manner of RAF pilots. 99% are perfectly competent and decent people. Some are exceptional and thoroughly modest. A very, very few, in my experience, are unbearably arrogant and, although they may have been ace fighter pilots, they were pretty dreadful civilian pilots.

Your post is a distraction from a far more fundamental problem which encompasses some deep and ingrained cultural issues some of which comes under the heading of CRM.

maajam

I find your reticence to state whether you are a pilot or not puzzling. It detracts from the value placed on your comments.

[ALI-SAFARI-IR.]

i think airbus pilots have a wrong view about flying with this model that this opinion is

not good and in some cases is dangerous that is:

computers and glass screens save you in last seconds !!!they think computers always

can control situations and prevent the accident.....

however its not only pilot error ;because airbus company is trying to eliminate pilots

and their rule in flight !!!

AS A RESULT for an airbus crash you dont need to structural damage -or -serious

engine failure but a autopilot problem can make serious problem for pilots because

as airbus company said:

THIS AIR PLANES IS FLYING WITH TECHNOLOGY.....

whats your mean man -is your mean that pilots are.....or they are pilot yet.?!!

[denlopviper]

mtwittm

You sound a wee bit like this chap Mekal from link below not sure though. I just wanted to know if you were a Pilot, because you seem to be flogging this issue to death as if you are fishing for information.
i know right?

[maajam]

I was, Sir, some time ago.

But suppose I was not. Why does that detract from what I say? Why does it diminish my credibility? I hope I talk aviation-sense, at least some of the time, and ask reasonable questions?

Surely, I am entitled to participate with members of this august forum from that stand-point alone, even as a lowly probationer?!

Do let me know if you think I am not and I will exit gracefully, with thanks for sharing your insights and expertise with me.

As for the author of the article, I don't know him personally but he is probably the only sensible and coherent writer on aviation matters in the country and I always read him. I don't know his background other than what is stated but he seems to be well-versed in the subject and often elicits favorable comments from readers. He also writes extensively on economic matters, a subject on which he is also very competent and highly respected (again based on readers' comments or articles which quote him).

The others who write on aviation-related matters are quite dreadful and even comments from the aviation authorities (the CAA) are amateurish. They are mostly retired former air-force officials from whom one would expect better.

There was a Letter to the Editor from somone residing in the Gulf castigating the CAA for a "third-rate" report. I do not share that view. It could have been better, and certainly longer than just 38 pages with more detail (full CVR/DFDR and maps and graphs), but it gets to the heart of the matter.

[M.Mouse]

Surely, I am entitled to participate with members of this august forum from that stand-point alone, even as a lowly probationer?!

Of course.

But suppose I was not. Why does that detract from what I say?

Not so much detract from what you say as put a different slant on your opinions. Any pilot will tell you that some situations in an aircraft cannot truly be understood unless you have the experience of being a pilot in the first place.

How many non-pilots can really imagine what it feels like to lose situational awareness or have things happening so fast that you are playing catch-up, something we have all experienced at some point in our flying careeers whether as low houred private pilot or an experienced commercial pilot having a bad day!

[BOAC]

It really is bizarre. If you recall dear old Meekal going on about some (possible) home-made unofficial R12 procedure (and like 411A getting terribly confused about circling...). The planned use of 'Nav' might hint at this but I cannot follow the PBD points inserted. Maybe someone could plot them? It seems finally that the a/c was roughly paralleling the downwind track but in the wrong place. How they finished up with 3000fpm down, IMC with terrain warnings I just cannot understand. It seems to me that the Captain had completely lost any idea of where he was or what he was doing and it really was classic 'time to take over' time.

[Flyer1015]

Is there a link to a clear report somewhere?

[alf5071h]

It is interesting to consider the similarities between this accident and AF447 (and others) – re “seems to me that … had completely lost any idea of where he was or what he was doing ...” (BOAC #104).
These accidents were self-made; the roots of the contributing causes occur much earlier in the event than the EGPWS warnings, or the ‘failures’ in the crew's CRM (or other meaningless terms).

In most aspects it is the lack or loss of appropriate awareness, understanding the situation, the changes, and the importance of unfolding events – triggers for change, which are the key issues.
In some respects the limitations in human performance also appear self-inflicted – mental incapacitation, inability to think; to evaluate, understand, plan, review, change, decide, and check. Perhaps the industry doesn’t get enough practice in these basic skills.

[maajam]

The PBS conundrum was mentioned in the report and it said it was unauthorized.

If so, why was it in the data-base?

I don't know.

Someone sent me a paraphrase of the report today. At one point he was 15 degrees nose-up. A 25 right bank was followed by a 54 degree left-bank applied manually. Before impact he was 5 degrees nose-down.

[maajam]

M. Mouse,

Sir, your comments are very astute and pertinent.

I hope my position is clear and it entitles me to be a member of this august Forum. My memories are a little faint and my knowledge needs constant up-dating. I am not so young anymore.

[4Greens]

The only two things we know about accidents is that there is never a single cause and also that there is always human error. To say the Captain caused the accident is incorrect. There are always other issues, not the least of which would be training.

[Clandestino]

How do you take control away from a captain who's still "controlling" the aircraft, without a fight ensuing?By setting the PRIORITY RIGHT.

[mangere1957]

jjeppson @ 24th Dec 2011, 04:20 post #23

"No matter what seat you are in, you don't just sit there while the other pilot tries to kill you! Where were these guys trained?"

Are you sure? It isn't quite that simple, even in the US Airforce let alone a third world Muslim country. Watch the short video linked below then research the lead-up.



B-52 Crash - YouTube

[bubbers44]

You can always take the aircraft away from your captain but you usually will lose your job in the process. I did it once in a 4 engine corporate jet landing on a wet runway at night with a strong crosswind on a short runway.

He was way high and unstabilized and he went to landing flaps and pulled the power off approaching the threshold. I said no we are going around and pushed the throttles up and went around. I thought I was for sure fired but wanted to stay alive. When we landed he thanked me. I was surprised. He was my Chief pilot. Don't ever let a pilot in the other seat endanger your flight. Left or Right.

[BOAC]

I have been thinking through this 'conundrum' of why fly so far out. It appears that the Captain 'thought' he was in NAV. There had been some attempt to programme some waypoints into the Sec FPL. Can it be that in his confused mind - in a sort of magenta line world - he 'thought' the machine was following the LNAV? Of course, any map display would clearly show divergence from the 'planned' route, but I do not think the report says what they were looking at. I can find no other explanation for length of time spent on the heading towards the hills. There had been discussion about a 5 mile downwind point, and if 'he' thought they were still going 'there', they could easily have arrived at 7 miles with the confusion over why it was not 'turning'.

I need a bit of input from the AB community here - the switching from ILS to HDG appears logical at DA and for the start of the circle. The Captain then 'thinks' he goes to NAV but stays in HDG, and at para 8:31 the report says the 'lateral mode was changed to NAV'. Can anyone suggest a clue as to what was going on? Presumably a switch to NAV when ?off? the planned LNAV route would engage wings level on existing heading?

[Centaurus]

To say the Captain caused the accident is incorrect.

When do you run out of excuses for crew members - be they captain or first officer? The buck stops with the aircraft captain. That is why he is paid to do the job of captain. Why not start right at the top and trace any blame right back to the bloody Prime Minister who should have supervised his Minister for Aviation who should have supervised his Director of Civil Aviation ad nauseum right down to the poor captain who had no choice but to run into a hill because everyone let him down.

I don't buy that nonsense:ugh:

[BOAC]

right down to the poor captain who had no choice but to run into a hill because everyone let him down.- Hmm! A strange view of command. Especially following The buck stops with the aircraft captain.Should we wrest control from Centaurus..............?

[maajam]

I would venture to say that which AP mode he was using and what he should have been using is the weakest -- and somewhat confusing -- part of the report except it notes he was using an "unauthorized" procedure.

I can only guess he stayed in NAV while he kept turning the Heading bug to the left, but did not engage it. Eventually he did, and the a/c turned right. At that point he seemed to be in state of complete panic, switching off the AP, over-banking the aircraft, pitching it up to 15 degrees at one point, followed by that unfathomable descent at the end.

I find it difficult to read the report again because it is becoming a very distressing read.

[Meikleour]

BOAC: On the Bus it is usual to have at least the opposite runway inserted in the SEC FLT PLAN when a " circle to land " is anticipated.
At the breakoff point from the ILS heading will be used to establish the turn into the circuit. At that point the PNF would normally ACTIVATE the SEC FLT PLAN and only then, could NAV be engaged again.
By PBD I assume the posters are referring to Place/Bearing/Distance pilot generated waypoints and hence these would not be in any data base.

[Shorrick Mk2]

The PBS conundrum was mentioned in the report and it said it was unauthorized.

If so, why was it in the data-base?


PBD are user-created waypoints and as such they are not "in the database" per se but rather added by the user. AFAIK there is no failsafe / crosscheck to manually adding a PBD (eg the FMS won't tell you if it's in the middle of a restricted area or below a mountain top).

"Unauthorised" doesn't mean the FMS will forcibly prevent you from entering such a PBD if you so wish. It means entering PBD's for that specific purpose (circle to land) and presumably that specific place was unauthorised.

[BOAC]

Meikle - I'm happy with that, but not sure what the NAV function on a circle to land would do for you - does it simply change runway or are you presented with an LNAV option for a visual manoeuvre?

Any comments on my last para?

[RoyHudd]

Was the P-B-D inserted into the primary flt plan, the secondary, or both? At what point exactly was the secondary activated?
Did the a/c have TERR ON ND function? If so, was it displayed? And if so, which ND? Was the radar on? Displayed properly? Which ND? And at what tilt?

Without knowing answers to these questions (and others, I am sure), we will never know what exactly happened, let alone why.

But from the transcript, it seems that something was stifling the FO from alerting, challenging, and ultimately taking control of the a/c. My guess is that the flight deck atmosphere was about as poisonous as that of G-ARPI, which Stanley Key presided over. And the old chestnut of abusive captain's incapacitation was raised in that accident as well.

[Ten-miles final]

BOAC
Meikle - I'm happy with that, but not sure what the NAV function on a circle to land would do for you - does it simply change runway or are you presented with an LNAV option for a visual manoeuvre?
Any comments on my last para?

Preparing secondary flight plan for opposite runway before circling does nothing to navigate the maneuver, it is used only to get benefit from ground speed mini function when you use managed speed. Airbus doesn't prohibit circling without activating secondary flight plan to opposite threshold but in latter case selected speed shall be used instead of managed. Like on any normal airplane circling is described in therms of headings and timings and not by NAV via pilot created PBDs.
The situations was further aggravated as captain turn the heading knob but didn't pull it and autoflight remained in NAV. This Bus feature (pull knob to switch to selected guidance) is really confusing and it's happened to me several times just to rotate and not pull noticing this error only by FMA readout. Being under stress captain rotated heading to 086 (as stated in the report) - too much to the left to intercept final - because airplane didn't do what he expected, so he continued to rotate heading bug up to 086. Finally, when he realized mistake he pulled heading knob and that's why airplane started right turn instead of left (to the shortest direction).
That's what I can imaging reading the report (IMHO).

[BOAC]

TMF - yes, I read it that way and thanks for explaining the Sec FPL function - which I see as a distraction to a visual manouevre.

I am still unable to understand WHAT the FMS was navigating on when NAV was selected. Assuming it needs waypoints (as per Boeing) then why was there a waypoint in that direction and what was it?

[M.Mouse]

This Bus feature (pull knob to switch to selected guidance) is really confusing and it's happened to me several times just to rotate and not pull noticing this error only by FMA readout.

Not sure why it should be confusing. On a Boeing the knob has to be pushed to engage HDG mode. Whichever aeroplane we are talking about HDG mode has to be selected by some method or other. The definitive indicator of mode selection is the FMA which is why SOPs in my company, and I would imagine most others, not to mention basic airmanship, is to read what the FMA is displaying!

Irrespective of the CRM issues previously discussed it is plain the captain was either subtly incapacitated or overloaded and confused. In high workload situations if confusion occurs the one thing you need but do not have is time to sit back and analyse the situation.

Despite the alleged bad atmosphere on the flight deck I would suggest that had the FO been situationally aware and been demonstrative in declaring he had control, what he was doing and why (i.e. 'I have control, turning left/right away from the hills, climbing to x feet') the captain would probably have acquiesced fully aware he had personally lost the plot.

What actions he took when he had composed himself or once on the ground is open to debate.

[Meikleour]

BOAC: As Ten Miles Final also posts - Managed NAV should NOT BE USED for a circle to land which is by definition a visual manoeuvre ----- however there has been a creeping trend amongst the "magenta line" generation to self build plans for these manoeuvres via PBD waypoints. The captain may have done this and then re-engaged NAV ( ie. managed nav. ) having done this if he then simply rotated the heading bug without then pulling it the aircraft would have continued in NAV longer than he anticipated.
A more usual use of the SEC FLT plan would be to give the correct GSmini reference and perhaps an extended certreline to avoid a flythrough.

I personally deplore the trend towards the view that since NAV is updated so accurately by GPS that it is OK to use it instead of looking out the window. Some youngsters are going to be in for a shock when they circle in a snowstorm and then have a map shift!! Still, us dinosaurs are in retreat!

[Ten-miles final]

Meikleour (http://www.pprune.org/members/183752-meikleour)

Agree with you - as far as GPS primary airplane is able to track very accurate, so we would be earning additional benefits staying in NAV (or tracking green dashed line in heading). Also useful for RNAV visual like in TLV.
I saw the video by RYR when downwind and final turn during circling on 737-800 is done referencing to map on ND end even changing bank angle selector on final turn to intercept inbound course very precisely.
I used to look for crosscheck to ND map from time to time when making final turn on visual approach.

[BOAC]

Meikle - where I need help is in understanding HOW there could possibly be a waypoint out towards the crash site for NAV to use. Any point out there could not be a part of the circle procedure - even for the 'magenta line crowd'. If they had programmed the turn point after the 45 offset, indeed that is more-or-less 'in line' with their track but the kit could surely not continue in NAV with that waypoint behind them?

TMF - I cannot see any way this gang were looking at the map display!

[Ten-miles final]

BOAC

I assume PBD waypoints were created and inserted into secondary flight plan before approach. Secondary flight plan had to be activated at some point after break off from ILS.
BTW, PBDs are numbered in sequence, so PBD10 means nine waypoints were constructed before and (possibly) some of them were rejected as they didn't met pilot expectation (my guess). Report refers to waypoint constructed as [PBD10 (place #10 defined by bearing and distance) northeast of the runway, that was to be placed on radial 026 at 5nm from the CF], navigating to this point assures too wide pattern comparing to timing procedure and obviously well outside protected airspace as this waypoint is located 7NM from threshold RW12 (right-angled triangle with cathetus of 5 NM so easy to understand that hypotenuse should be 7NM).

[Ten-miles final]

BOAC

PBD 10 was defining end of downwind for RW12 and starting base turn, that's why it was located ahead of them, not behind. Captain constructed almost racetrack pattern for RW12 using as reference CF12 (this one was derived from FMGS automatically after selecting RW12 approach).
Imagine: 026 degrees, 5 NM is at right angle to final segment to RW12 to the North-East, for left hand base.
Again, flying circling in NAV is not stipulated in any Bus documents (AFAIK), but this unpublished procedure was for unknown reason selected by captain to shoot approach.

[BOAC]

Aha! I think I can see what the Captain was doing, although it makes no sense. PJ2 helpfully posted this image on the original thread. It shows the PansOps circling area. crash site and track to the site from airfield centre. I have added to it:

The Right-hand red diamond is PBD10, the left PBD11, NB both at 5nm, and outside the Circling 'protected area'. The black line to the left-hand diamond is roughly from break-off from the ILS to PBD11 and takes you pretty close to the crash site.

It appears that for no logical reason, he was Nav-ing to a point 5 nm at 90deg to CF12.

Case closed. Crash-axe job IMO.

http://img.photobucket.com/albums/v293/boacphotos/AirBlue-2.jpg

[Ten-miles final]

Exactly.
Very useful picture to comprehend. Sad story...
Anyway life's going on so I wish all aviation colleagues happy new year and safe flights.

[aterpster]

ICAO is overdue in developing circle to land database procedures using a combination of TF and RF legs that would execute the maneuver and remain within PANS-OPS protected airspace. Both the track and the MDA could be coded, thus freeing the crew of an advanced airplane to spend more time looking outside.

The FAA can't do it with their present very small circle to land airspace.

[maajam]

Gentlemen,

As jet-lagged as I am, and soon off on another long 20 hour east-west trip, I find your comments stimulating and quite brilliant in coming to grips with this tragedy.

I will read it again when I am feeling less disoriented.

While not detracting from the value of your hypothesis, I fail to understand how someone who, over the course of 35 years of flying during which he must have made 20-30 (?) approaches to 12, could have erred so greviously and with such devastating effect.

The statement that even "highly experienced pilot's make mistakes", while true and corroborated by the evidence, has always left me feeling a little perplexed and cold.

[BOAC]

thus freeing the crew of an advanced airplane to spend more time looking outside. - except why should they bother?

I think we need to stop ICAO right now. By all means 'code' an approach to a different runway, but let's not make a CTL effectively an IMC procedure UNLESS we re-write the books on what it is.

[Ten-miles final]

Impetuous development of PBN may reduce significantly need for CTL and even completely replace it for appropriatly equipped aircraft. On another hand that is not an answer for enormous number of old planes which are compelled to make CTL.
But accurately done CTL under suitable weather is a safe maneuver and in this particular case problem not with CTL but within way the procedure was planned and executed.

[aterpster]

BOAC:

- except why should they bother?

I think we need to stop ICAO right now. By all means 'code' an approach to a different runway, but let's not make a CTL effectively an IMC procedure UNLESS we re-write the books on what it is.

That is a valid argument. The same argument was made about Charted Visual Flight Procedures (CVFP) when they first appeared in the U.S.

As to a database circle to land, the navigation performance requirements would be far less stringent than with IMC performance based navigation.

An RNP AR approach to OPRN Runway 12 would fit very nicely, but because of the stringent aircraft and pilot qualification requirements for RNP AR, only a small percentage of the operations into OPRN would be qualified.

A VMC circle-to-land database procedure would require far less stringent performance based navigation requirements. The presumption would be that the crew has sufficient discipline to use the procedure only in VMC, with weather conditions at, or above, CTL minimums.

The obvious trade-off, as you point out, would be the temptation for some to cheat. I believe the safety improvements would more than offset the cheaters.

[ManaAdaSystem]

The statement that even "highly experienced pilot's make mistakes", while true and corroborated by the evidence, has always left me feeling a little perplexed and cold.

25500 hours, most of them spent staring out of the windows (or in the bunk) on a auto pilot controlled 747 cruising at FL 350. 4-6 landings pr month. What exactly do you expect from such a highly experienced and past 60 pilot?

Ace handling skills?

[fireflybob]

The statement that even "highly experienced pilot's make mistakes", while true and corroborated by the evidence, has always left me feeling a little perplexed and cold.

Captains are paid not to make mistakes and First Officers are paid to make sure they don't!

If a football teams loses 30 goals to nil, would you blame it all on the goalkeeper?

[BOAC]

would you blame it all on the goalkeeper - no - we would fire the manager!:hmm:

[M.Mouse]

Ace handling skills?

From my experience and observations I don't see the opposite.

How many landings a month do you think you need to be competent? It is also unlikely that a 22,500 hour pilot will have spent all his/her career doing what you rather simplistically quote.

[fireflybob]

- no - we would fire the manager!


Quite, BOAC!

[Sunnyjohn]

While not detracting from the value of your hypothesis, I fail to understand how someone who, over the course of 35 years of flying during which he must have made 20-30 (?) approaches to 12, could have erred so greviously and with such devastating effect.
Maajam - thank you - I have been wondering exactly the same thing. There has been just one post on this thread postulating a medical problem. It seems to me that this captain was suffering from some form of medical situation which impaired his judgement and capabilities. A serious angina attack could do this and there are precedents in previous disasters. Some of you may remember the 1972 BEA Trident crash. This is a summary of the captain's state of health prior to and at the time of the disaster:
The pathologist stated that Captain Key had a pre-existing heart condition, atherosclerosis, and had suffered a potentially distressing arterial event caused by raised blood pressure typical of stress. (This event was popularly interpreted by the public as a heart attack.)[56] It had taken place "not more than two hours before the death and not less than about a minute" according to the pathologist's opinion given as evidence during the public http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/editor/quote.gifinquiry
It seems to me entirely possible that a similar health problem could have reduced the judgement of the captain of this flight.

[maajam]

I am feeling less groggy today but dread my up-coming 14 hours, a stop, and another three hours to destination.

I have read the previous comments. They are excellent and I thank you and will read them again.

Just a few half-groggy comments:

The SFP was selected on the down-wind leg -- well, sort-of downwind -- as per the report.

If there were not looking at the ND at all, then they would not have noticed that "CF", the extended center-line of 12, was not visible, or was at at a rather awkward angle.

The use of PBD way-points is unauthorized but the F/O duly created them under instructions from the Capt. and did not object/protest. Maye he he did not know either.

They asked three times for a right downwind when one would imagine/hope that the Capt. should have known after 35 years, that it is not available.

I would have thought that the "pull" to engage the HDG knob was intuitive (not familiar with "glass"). "Pull" means YOU take control, and PUSH means you surrender it to the AP.

But I stand to be corrected.

On "experience". Points well-taken.

So where does that leave us?

When, as a passenger you see someone with those four stripes and silver hair, are you not 'assured', even if he has been sleeping in a bunk at FL350 half his life, that you are in "safe" hands?

You are not supposed to know that!

I know a pilot friend of mine who flies the Islamabad-Toronto route on the 777-200LR. He tells me that after TO and in the cruise, he retires to his bunk and sleeps for seven-eight hours (better sleep than he probably gets at home, with no distractions).

PIA has TWO full captains on these long-distance flights and one Capt. is always on the flight-deck (maybe AF can learn something from that after the AF447 accident).

So, what is "experience"?

Is it meaningless?

If I was on that fateful AB flight and it was announced that the Capt. was Pervez Iqbal Choudhry and I knew something about him, I would have exhaled and relaxed, knowing I was is not only good hands , but GREAT hands!


I wish you all a happy and safe new year.

[Machinbird]

This Bus feature (pull knob to switch to selected guidance) is really confusing and it's happened to me several times just to rotate and not pull noticing this error only by FMA readout. Not sure why it should be confusing. On a Boeing the knob has to be pushed to engage HDG mode. Whichever aeroplane we are talking about HDG mode has to be selected by some method or other. The definitive indicator of mode selection is the FMA which is why SOPs in my company, and I would imagine most others, not to mention basic airmanship, is to read what the FMA is displaying!
I am surprised that more fuss was not made over the underlined sentence. Here we have a longtime Boeing pilot in a 'Bus.

Haven't you folks found that certain motions you have learned on prior machines will come back to haunt you in bad ways?

[golfyankeesierra]

I am surprised that more fuss was not made over the underlined sentence. Here we have a longtime Boeing pilot in a 'Bus.

Haven't you folks found that certain motions you have learned on prior machines will come back to haunt you in bad ways?
Yes, but now it is AB vs Boeing. It used to be the same little nuisances with Douglas vs Boeing conversions (Hdg, landing lights, split radio tuning)

[A330ETOPS]

Im not suprised. Looking at the cockpit transcript doesnt suprise me. I was in the sim not so long ago with an ex-Air blue pilot. Claimed to have 8000 hrs on the bus.

He crashed 3 times, couldnt hand fly at all, and didnt know his QDM from his QDR.

He didnt pass of course.
I'd never step foot on an AP registered aircraft

[Admiral346]

You can always take the aircraft away from your captain but you usually will lose your job in the process. I did it once in a 4 engine corporate jet landing on a wet runway at night with a strong crosswind on a short runway.

I'd be grateful, I do wanna see mom and kids after my tour. What happened to you?

When we landed he thanked me. I was surprised.

See, that's what I would do. Anyone of us can get disoriented, that's what you need the other guy for.

And to constantly go: "please sir, turn left sir" is clearly missing the point of being an FO.

[Kal Niranjan]

You can always take the aircraft away from your captain but you usually will lose your job in the process. I did it once in a 4 engine corporate jet landing on a wet runway at night with a strong crosswind on a short runway.

When we landed he thanked me. I was surprised

Never fail to amaze me, this propensity to accomplish great feats of heroism!:D:D:D

[Superpilot]

Airblue crash investigation: Captain's son to challenge govt report (http://tribune.com.pk/story/313015/airblue-crash-investigation-captains-son-to-challenge-govt-report-national/)

[Peter Fox]

Machinbird,

its not how you imagine it.

I have flown both the B737NG and the A320.

On the 737, in order to select Heading, you need to push a button that is below the "round" Heading Select Knob to engage HDG mode and get out of LNAV. I doubt it is different on the B747. I have not flown the B747 but looking at the MCP it appears to be almost identical. On the 737NG you could not push the HDG knob, you could only twist/rotate it. To engage LNAV you need to press the LNAV button.

On the Airbus you need to pull the Heading Select Knob to engage HDG. You push it to engage Managed Nav.

In my opinion, you can not confuse the two methods of selecting Heading.

[Machinbird]

In my opinion, you can not confuse the two methods of selecting Heading.
Thank you Peter Fox. I found a picture of what appears to be a similar heading select system to the 747-367 that the Capt likely garnered most of his flight time on. What I see is a heading select knob with a rotary knob next to it to select the mode. I think you are correct. The operations would be very different with little carry over.

[newscaster]

The report is now officially posted at CAA site http://www.caapakistan.com.pk/downloads/Investigation%20Report%20-ABQ-202.pdf

[mtwittm]

Hi Maajam

Hope the fog of jet lag has worn off. Check out the the Air Crash Investigations video on the Air Inter airbus crash in Germany. There are some striking similarities with the Air Blue crash.

L1IwGn-BT7E
Questions which arose were:
-Auto Pilot malfunction.
-Automation and human interface confusion
-Traps in automation
-Air Traffic control miscommunication

[newscaster]

Not just the Captains son but now also the victims families are not satisfied with the report Airblue crash probe report vexes victims (http://www.pakistantoday.com.pk/2012/01/airblue-crash-probe-report-vexes-victims%E2%80%99-families/)

[BOAC]

Captain's son and victims families, while they may well have justifiable grievances over the composition of the board, will have a hard time trying to prove it was not a crew error. Map shift, autopilot or nav system malfunction be it as it may, there can be no way the Captain was maintaining 'visual contact with the runway environment' and thus was improperly conducting the manoeuvre he was supposed to be flying.

[bubbers44]

Kal, it wasn't heroism, it was self preservation that made me take the airplane away and go around. I knew I would be fired when I did it but it never happened. My ego doesn't require proving I am better. I just wanted to live another day. Sliding off the end of a wet runway doing everything wrong didn't fit into my future plans of my aviation career. I am retired now so don't have to deal with it.

[newscaster]

Apparently BEA and Airbus found CAA description of the Captain's behaviour unsavoury, quoting info from a poster at PIA fan site forum.

"The following comment on a draft report was provided by BEA and Airbus on the final draft of the report:

"However, some sections of the draft report use harsh words to describe the crew’s behaviour.
Annex 13, paragraph 3.1 states that the objective of the investigation is not to apportion blame
or liability. This is also reminded in the chapter 2 of your draft report. Therefore, the BEA
suggests re-wording some parts of the draft final in order to soften the criticism towards the
crew."

Sadly, it would appear that this comment did not make into the final version as the report definitively apportions blame on the crew."

[Capn Bloggs]

PBDs in the gloop in the weeds. :cool:

Please tell me it's not true that the Airbus always turns the shortest way to the Heading bug!

[IcePack]

It does just like a Boeing (if you turn the bug to a heading & then engage heading)

[punkalouver]

Apparently BEA and Airbus found CAA description of the Captain's behaviour unsavoury, quoting info from a poster at PIA fan site forum.

"The following comment on a draft report was provided by BEA and Airbus on the final draft of the report:

"However, some sections of the draft report use harsh words to describe the crew’s behaviour.
Annex 13, paragraph 3.1 states that the objective of the investigation is not to apportion blame
or liability. This is also reminded in the chapter 2 of your draft report. Therefore, the BEA
suggests re-wording some parts of the draft final in order to soften the criticism towards the
crew."

Sadly, it would appear that this comment did not make into the final version as the report definitively apportions blame on the crew."

Oh, I don't know. Maybe it is about time that the proper words were actually said. In this case, it appears that the captain was an AXXHOLE. Seeing as the report did not actually say that, perhaps it has been understated.

[Gretchenfrage]

Please tell me it's not true that the Airbus always turns the shortest way to the Heading bug!

It does, and it's a very common happening, as mentioned even on Boeings.

... and the good old MD11 showed a dotted line on the PFD to indicate which direction it will turn!
Just why wouldn't the two other engineering teams not adopt such a great feature??

"We always strive for the utmost safety" is a commonly read statement.
But it never passes engineers pride, it seems.
Never admit that the competition got it better ........

[Capn Bloggs]

... and the good old MD11 showed a dotted line on the PFD to indicate which direction it will turn!

As does the 717 (naturally). Great feature. :D

[Ten-miles final]

... and the good old MD11 showed a dotted line on the PFD to indicate which direction it will turn!...

Yes, that's really helpful feature we don't have on A nor B nowadays.
But in Airblue situation I believe captain was under so high stress and frustration while turning heading knob so even such feature wouldn't help him to realize the picture IMHO

[Capn Bloggs]

But in Airblue situation I believe captain was under so high stress and frustration while turning heading knob so even such feature wouldn't help him to realize the picture IMHO
On the contrary, it would in all probability have saved them. The reason they clobbered the hill was because the aircraft turned right initially because that was the shortest way to the final position of the heading bug. If it had turned left when HDG was selected, the direction in which the heading bug had been turned, they probably would have missed the hill.

[BOAC]

No.TMF is right. Since the Captain appeared to be unaware of his pitch or bank angles or position much of the time I doubt a wiggly little line on the EHSI would have even been noticed. Let's get real here.

[Gretchenfrage]

The captain might have missed it, but the possibility remains that he might have not.

Any help in a scr@wed-up situation is not only welcome, but imperative, if you really are serious about accident preventing.

Such a feature exists and is simple and cheap to reprogram.

Why not go for it?

(Scared of lawsuits I guess .... lawyers seem to be one of the greater enemies of airline safety improvements)

[J.O.]

The mess was made long before the heading bug got involved. Any pilot who would have been awake enough to see a dotted line and interpret its meaning would also have been awake enough to have never got that far in the first place, IMO.

[aterpster]

Capn Bloggs:

On the contrary, it would in all probability have saved them. The reason they clobbered the hill was because the aircraft turned right initially because that was the shortest way to the final position of the heading bug. If it had turned left when HDG was selected, the direction in which the heading bug had been turned, they probably would have missed the hill.

It depends on how late the right turn was made. This is the topography of the crash site:

http://i201.photobucket.com/albums/aa214/aterpster/AirBluecrashsite.jpg

[Gretchenfrage]

The mess was made long before the heading bug got involved. Any pilot who would have been awake enough to see a dotted line and interpret its meaning would also have been awake enough to have never got that far in the first place, IMO

Absolutely! It takes way more for a mess like that.

But it's another hole in the Swiss Cheese, and as I said: We (and the industry) should all strive to eliminate every hole, shouldn't we?

[Ten-miles final]

...But it's another hole in the Swiss Cheese, and as I said: We (and the industry) should all strive to eliminate every hole, shouldn't we?..

No doubts, agree. This simple feature could help in thousands less dramatic events.
The latest one I saw this evening sitting in the sim ;)
Heading bug rotated much further then it was requested by "ATC" instruction while attempting to expedite the turn (that's true, very often pilots do this unconsciously!) resulted in rotation into opposite direction.

[Capn Bloggs]

It depends on how late the right turn was made. This is the topography of the crash site:
Thanks. The scale from your diag is not clear, but looking at the map on page 26 of the report, based on the length of the runway, I guesstimate that the aircraft would have been at least 1nm further southeast had it turned left immediately the Captain pulled Heading.

[aterpster]

Capn Bloggs:

Thanks. The scale from your diag is not clear, but looking at the map on page 26 of the report, based on the length of the runway, I guesstimate that the aircraft would have been at least 1nm further southeast had it turned left immediately the Captain pulled Heading.

Here is a diagram that may be more useful with scale and the Jeppesen plan view. You can relate this to the diagram on Page 26 of the report and perhaps decide whether a left turn would have saved the day.

My orange CTL is PANS-OPS CAT D so it is a bit larger than the investigator's CAT C CTL area.

http://i201.photobucket.com/albums/aa214/aterpster/OPRNJeppPV.jpg

[BOAC]

You are all piddling in the grass at the side of the road. At the time of impact the descent rate was 3000fpm. Left turn/right turn??:ugh:

[J.O.]

You are all piddling in the grass at the side of the road. At the time of impact the descent rate was 3000fpm. Left turn/right turn??:ugh:

:D

Precisely. If every hole in the cheese is ever to be plugged, the result will be a large collection of airport fences that are lined with parked airplanes. And PPRuNe will be as useful as nipples on a bull.

[aterpster]

BOAC:

You are all piddling in the grass at the side of the road. At the time of impact the descent rate was 3000fpm. Left turn/right turn??:ugh:

No, you're not reading the time line in full. After the heading was selected incorrectly the airplane subsquently climbed before it went into its final high desent rate to impact.

[BOAC]

Oh yes I am - it is quite apparent (from the reported manoeuvres) that the Captain had completely lost the plot and probably did not even know what day it was. Add to that an F/O who, to paraphrase 'J.O' - was as useful as 'tits on a nun', and persuade me that either of them had any idea what heading was actually selected - or why. As to which way it was 'going to turn' with bank angles of 50deg+ !!! Come on. There was only ONE direction they should have been going, and it wasn't left or right - as a clue, and nor was it in 'Autopilot'. This is like straightening the deck chairs on the Titanic.

[aterpster]

BOAC:

Oh yes I am - it is quite apparent (from the reported manoeuvres) that the Captain had completely lost the plot and probably did not even know what day it was. Add to that an F/O who, to paraphrase 'J.O' - was as useful as 'tits on a nun', and persuade me that either of them had any idea what heading was actually selected - or why. As to which way it was 'going to turn' with bank angles of 50deg+ !!! Come on. There was only ONE direction they should have been going, and it wasn't left or right - as a clue, and nor was it in 'Autopilot'. This is like straightening the deck chairs on the Titanic.

The only point I was making that your previous statement disagreed with the time line. Now, you bring in the captain's state of mind. You're certainly right on that one, but that doesn't change the fact the airplane probably could have been saved by the F/O after the right turn begain.

The aerodynamics at that point in time permitted a save; neither pilot took advantage of the time remaining.

[bubbers44]

It looks like it could have been saved by a competent FO. Guess that wasn't happening that day.

[Dan Winterland]

''ICAOis overdue in developing circle to land database procedures using a combination of TF and RF legs that would execute the maneuver and remain within PANS-OPS protected airspace. Both the track and the MDA could be coded, thus freeing the crew of an advanced airplane to spend more time looking outside.

The FAA can't do it with their present very small circle to land airspace.''

They can, it's just going to be very tight. Pusan in Korea uses TERPS and the circling approach onto the 18L/R is very challenging. A series of waypoints 'draws' the limits of the circling area on the ND for the crew to stay within. I't's tight, but easliy acheivable - although those who have flown the procedure may question the 'easy' bit. And an RNAV circling approach onto these runways is being developed apparently. And before anyone asks, I have no idea what an RNAV circling approach will look like or how it will be flown.

[Dan Winterland]

As for the Airbus heading bug, if you engage the HDG mode by pulling the knob before you turn it, it will follow the direction of the turn regardless of the heading set.

[BOAC]

This is all getting very confused! IF an RNAV pattern (let's call it a 'CIRCLE' although it won't be) is constructed, it will NOT need to be constrained by a TERPS or PANSOPS circling area, since it will be drawn (and hopefully flown) avoiding KNOWN obstructions. In fact it will not need ANY sort of 'area' constructed. Nor would it need 'visual contact with the runway environment'.

I can see very few airports where this will be necessary - there are of course some (please don't start listing them!) - but the vast majority will be better served by a properly constructed RNAV approach directly to the runway in question, where 'traditional' approaches do not exist.

I still suspect that AirBlue set out to fly some 'secret handshake' homebuilt RNAV pattern onto R12 (as hinted at by the poster way back on the original thread) and simply screwed up big time.

[fireflybob]

I can see very few airports where this will be necessary - there are of course some (please don't start listing them!) - but the vast majority will be better served by a properly constructed RNAV approach directly to the runway in question, where 'traditional' approaches do not exist.

I still suspect that AirBlue set out to fly some 'secret handshake' homebuilt RNAV pattern onto R12 (as hinted at by the poster way back on the original thread) and simply screwed up big time.

BOAC - agree 100%!

With all the kit on board modern aircraft direct approaches should be coded in the database - far safer than clambering around a circle to land in marginal conditions.

Ok yes there is a certification issue but the authorities and the operators need to get going on this stuff asap.

[Gretchenfrage]

BOAC and fireflybob

I agree as well.

Mainly because most modern 'pilots' can no longer fly visual circuits.

[fireflybob]

Mainly because most modern 'pilots' can no longer fly visual circuits.

Gretchenfrage, sadly so true.

[BOAC]

Judging by the 'comments/surprise' when I briefed and flew Visuals on the 737 in Astraeus and BA (yes, I know...................:)), very few Captains seemed to do it and I nearly always had to 'persuade' an F/O to try one and then talk him round it. Sad days. If it ain't an ILS in CAVOK I ain't doing it................

[Dan Winterland]

"In fact it will not need ANY sort of 'area' constructed. Nor would it need 'visual contact with the runway environment'."

Apparently, this one in Pusan will. I don't know the details yet - it's still being developed but it appears it will be RNAV guidance for the visual element of the circling approach. Interestingly, it will have to conform the the TERPs circling minima - this is one of your exceptions. An Air China 767 crew discovered there isn't much room for lattitude about ten years ago.

[BOAC]

Interested in any link? I am not sure I am easy with 'RNAV guidance for a visual' for reasons expressed a few pages back to Aterp - especially with TERPS areas.

[HundredPercentPlease]

Heading knobs!

Surely this was a simple case of subtle incapacitation combined with a lack of intervention by the FO.

The Captain showed signs of anxiety, preoccupation, confusion and geographical
disorientation in various phases of flight especially after commencement of
descent.

FO kept watching the Captain’s failures, and unsafe actions such as inducing
steep banks; and continuous flight into hilly terrain at low altitude in poor visibility;
and failure to apply power and pull up. Unfortunately, FO remained impassive
and failed to assert himself due to non congenial environment in the cockpit.

Those are the two primary causes, all the other guff is simply a list of consequences of the those primary causes. If the captain was that poor as normal, he would have crashed decades ago.

[Denti]

This is all getting very confused! IF an RNAV pattern (let's call it a 'CIRCLE' although it won't be) is constructed, it will NOT need to be constrained by a TERPS or PANSOPS circling area, since it will be drawn (and hopefully flown) avoiding KNOWN obstructions. In fact it will not need ANY sort of 'area' constructed. Nor would it need 'visual contact with the runway environment'.


Interesting opinion. I flew yesterday a nice and easy RNAVV in LLBG. You need visual contact with the runway to descend below 3000ft, therefore you need to be visual the same as during a normal visual approach. There are other airports that have visual approaches with prescribed tracks as well, for example LFMN. Dunno how you would see those under your cited presumptions.

[HundredPercentPlease]

BOAC,

Here is the RNAV Visual that Denti (and I) fly regularly. Always happens to the South, and makes for an efficient and low-stress arrival.

http://dl.dropbox.com/u/37912564/llbg26.pdf

[BOAC]

Sorry, Denti - I think you have missed the whole point!There are other airports that have visual approaches with prescribed tracks as well, for example LFMN. Dunno how you would see those under your cited presumptions. - all 'new' RNAV 'circling' procedures would by definition be 'prescribed tracks'. 'Prescribed' in a DB and flown by the autopilot. That is the whole point. None of the examples you quote have any relevance to what is being discussed.

100% - likewise that is not what is being considered - that is simply a visual approach with 'preferred tracks' arranged to suit traffic flow, nothing else, and nothing like a current 'Terps circle" (well outside the restricted area) and just would not be flyable under current 'circling' minima which is the whole point of an RNAV 'circle' as being discussed.

Is that the only visual option now in TLV for R26? I guess some see that as progress.............................

[Sunnyjohn]

Surely this was a simple case of subtle incapacitation combined with a lack of intervention by the FO.
I agree. There is always a lot of postings regarding technical, navigational and meteoroogical aspects but I have noticed a marked reluctance on these forums - not just this one - to consider or discuss the physical or mental state of the crew. Why is that?:

[BOAC]

I have noticed a marked reluctance on these forums - not just this one - to consider or discuss the physical or metal state of the crew. Why is that?: - don't know but does not apply on this thread.

[Sunnyjohn]

Well, yes, it does. I've just been through the 193 posts on this forum and only six of them refer to the captain's physical health, two of which were mine. It is true that there have been a number of posts regarding CRM but not with regard to the actual mental state of the pilot - I counted two. That's eight out of 193. When one considers that the mental and physical well-being of the crew is one of the most important aspects of aircraft safety, I have to repeat that I am surprised that there is not more discussion on this and I wonder why.

[BOAC]

Well, I am with you, but remember the other factors you list are still important in trying to reduce 'pilot error' accidents like this. A reduction in the physical and mental state of the crew is only really resolved by the unliklihood that both pilots will suffer the same together. I believe there is still 'mileage' to come on the accident report as evinced by the 'missing' bits referred to earlier. There is a lot of regional/national 'pride' involved here too, and the 'truth' may never become public. I would suggest that there is not really much value in discussing the 'mental' issues and that few posters here - outside the region - would deny the apparent cause.

[aterpster]

HundredPercent:

Here is the RNAV Visual that Denti (and I) fly regularly. Always happens to the South, and makes for an efficient and low-stress arrival.

Interesting "Ceiling Required" yet not specified.

[BOAC]

That is because 'visual with the ground' is required below 3000' and altitudes are specified therefore no need. There is no minimum ceiling for a visual approach that I am aware of.

[HundredPercentPlease]

It does - just below (3000'). The "Ceiling Required" in explained in the Jepp text.

[aterpster]

HundredPercentPlease:

It does - just below (3000'). The "Ceiling Required" in explained in the Jepp text.

Well, yes, that is a condition but not exactly a required ceiling. Charted Visual Flight Procedures (CVFP) in the U.S. have a specific charted minimum ceiling and visibility published. It tends to keep folks on both sides of the mic honest.

[BOAC]

Leaving visuals into TLV aside, are there any examples of the development of an RNAV circling type approach? OBN/Aterp?

[Zeffy]

OK465You don't have to call it a 'circling approach' if you don't want to, but it is...

Straight-in only -- no circle to land minimums.

Six nm final segment; gun-barrreled to the rwy centerline...

Probably eligible for designation of "Straight-in", eh?

:ok:


http://i202.photobucket.com/albums/aa92/zeffy_bucket/KRNO-RNP16L.png

[BOAC]

Look at the RNAV (RNP) 'Y' to 16L or 16R at KRNO.Don't think I can

It is, however, a 'guided' RNAV approach track starting from a position equivalent to a 'circling' downwind and with 'circling' track guidance on the RF turn. Can be FD hand flown or coupled. - Perhaps I have misunderstood the way we are trying to go? I thought we were looking at an RNAV IMC flown pattern (with suitable ANP) around an airfield and down to a DH on a runway?

You don't have to call it a 'circling approach' if you don't want to, but it is... - no, it cannot be called that or there will be utter confusion. Let's have a PPRune 'New Name' competition for this procedure.:)

Edit - thanks Zeffy - yes, that is getting there - IMC to around 500' on final.

[Zeffy]

Don't think I can

Of course you can !

Simply click here (http://aeronav.faa.gov/index.asp?xml=aeronav/applications/d_tpp) for many hours of free downloading. :)

[Sunnyjohn]

When one considers that the mental and physical well-being of the crew is one of the most important aspects of aircraft safety, I have to repeat that I am surprised that there is not more discussion on this and I wonder why.

Having given it some thought it occurs to me that the majority pf posters (other than the trolls) post about things of which they know much - like technical details, meteorology and navigation, as one would expect from highly trained and experienced personnel. I can still remember my five year training with (then) BEA and I can still recall some of the systems and circuits we studied for the Vanguard and Viscount. I recall little about human behaviour. I suspect this is still true. We may receive training in systems, CRM and human behaviour but it's the day to day stuff that we use and remember. We don't usually have to think about our state of health or the psychology of our mind so any training in that regard is lost. Therefore, very few people on this forum have much recall of knowledge or interest in these things. This is unfortunate bearing in mind that the person at the front is still a human and subject to all the frailties that come with being one. We should take more interest in these things but we don't. So when a disaster could be explained by a failure of a human in medical or psychological terms, nobody has sufficient recall to discuss it. Just a theory . . .

[FLCH]

I agree this is more about the psychological aspects of the pilots flying rather than the technical aspects.

The confusion of what to do and when to do things is what is important, but some on these boards choose to focus on what they know rather than what really happened.

Shame.....

[aterpster]

BOAC:

Leaving visuals into TLV aside, are there any examples of the development of an RNAV circling type approach? OBN/Aterp?

None in the U.S. But, the U.S. presently has 292 RNP AR IAPs, many of which have curved flight paths (ARINC radius-to-fix, or "RF" legs) to avoid terrain and line up with final. These are IMC approaches to a DA.

I would envision an RNAV circle to land to be "assisted" circle to land in VMC. I think you and I agree that it may turn out to not be such a good idea.

The bar is set quite high to play in the RNP AR sandbox, but the Air Bus that crashed fully meets the airframe and avionics requirements for RNP AR. The other part of the equation is crew and flight ops technical qualifications.

But, the terrain at OPRN would support a conventional RNAV IAP quite easily. It could even arrive far enough from the northwest over the mountains where no part of the procedure would have to pass over the restricted airspace to the south of Runway 12's final approach course.

[HarryMann]

Ergonomics... again. Pull to select HDG knob, instead of push as in Boeing... why are these basics not determined to be consistent, its almost as if AB just has to be different, or to be fair, Boeing has to be different, whoever came first.

No, of course it didn't cause this accident, I am just musing on ergonomics and behaviour reversion under stress...

[bubbers44]

Guess circling approaches were easier when I did them 8 years ago. They were quite simple back then. You kept the airport in site and circled. What have they done to make if difficult now?

[Aztec Kid]

While not truly circling approaches, here are two containing the “RF” segments mentioned by aterpster. The first initially overflies the IF for the ILS to 22L at EWR, and breaks off for a landing on 29. The second approach to 29 overflies the FAF for the ILS to 04R.

The DAs for these approaches are lower than the MDAs for the ILS circling approaches.

http://aeronav.faa.gov/d-tpp/1201/00285RRY29.PDF

http://aeronav.faa.gov/d-tpp/1201/00285RRZ29.PDF

[BOAC]

Thanks, Zeffy - I had edited my post following your graphic.

Aztec - images not showing for me.

All - this does not really relate to Islamabad where I think we all agree a R12 RNAV approach would have been easy. It is more a ?logical? extension of all the work on curved MLS approaches etc etc into a full RNAV curved 'circle'.

[Aztec Kid]

BOAC,

I hope these links will enable you to view the charts.

Best regards,
The Kid

http://aeronav.faa.gov/d-tpp/1201/00285RRY29.PDF

http://aeronav.faa.gov/d-tpp/1201/00285RRZ29.PDF

[Capn Bloggs]

Pull to select HDG knob, instead of push as in Boeing... why are these basics not determined to be consistent, its almost as if AB just has to be different, or to be fair, Boeing has to be different, whoever came first.

MD 717/MD11 also pulls the HDG knob to engage HDG or TRK mode. Boeing's the odd one out. :ok:

[pontifex]

Sunnyjohn,

Not true. Human frailty was discussed in condiderable depth in the MCC course I ran up to about three years ago. The pressures that might bear on a pilots performance such as financial, domestic, work or union related and many others were raised either by myself or my students. It was emphasised that a PNF should always be alert to the posibility of these factors affecting either them or their PF. It actually formed a significant element in my human factors teaching. Don't know how others did/do it, but I am sure it is fully covered. May be different in other parts of the world of course.

[Capn Bloggs]

Aterpster,
Thanks for the chart. Just got back from a trip hence the delay. They would have gone very close to getting away with it had the machine turned in the direction the HDG bug was wound.

RNAV-RNP look like they are fantastic, but that complexity is not needed here. A simple RNAV(GNSS)/RNP APCH-LNAV approach with a 10nm final would have done the trick.

[BOAC]

All this focus on push/pull etc the HDG knob gives me great concern. We have a serviceable aircraft, 2 qualified pilots, and an aircraft that does not do what is being demanded or expected through the automatic flight system.

Let me see - how does it go?

SWITCH IT OFF AND FLY THE ****AEROPLANE!

It would not matter a damn if every AFCS worked exactly the same way all over the world. If pilots cannot undertake this simple act of 'flying' it would make no difference.

Thanks Aztec - they look just as I envisaged.

[Sunnyjohn]

Not true. Human frailty was discussed in condiderable depth in the MCC course I ran up to about three years ago.

Thanks for this. I hoped this would be the case. How well do you think folk would recall such training?

[BOAC]

Sunny - this goes well past CRM issues. What we appear to have had here is a complete collapse in the survival instinct from the F/O. I cannot understand it and from my (Western) military experience I cannot envisage any current or ex-miltary pilot allowing him or herself to be wiped across a hillside just because they were 'upset'.

I do not think ANY amount of MCC/CRM/psychology-whatever-you-call-it training would prepare someone for this scenario. Surely it comes down to a basic survival instinct? At what point do you expect 'folk' to recall that?

[bubbers44]

Doing a circling approach doesn't require survival instincts because they should be well instilled long before this if you have flown for a while. Circling approaches are done all the time with no automation at all.

After doing thousands of them with no problem with no automation hope how to use the heading button with automation makes them unsafe is kind of sad. Automation is great if the pilots can fly as well as the automation. If they can't they shouldn't be flying. Did some pilots become monitors of automation and depend on it in the last years?

I hope not but in a lot of cases it has reading here.

[aterpster]

Capn Bloggs:

RNAV-RNP look like they are fantastic, but that complexity is not needed here. A simple RNAV(GNSS)/RNP APCH-LNAV approach with a 10nm final would have done the trick.

Or even a VOR/DME approach with an arc initial segment that avoids the imperial areas. Then again, the VOR may not be performing well enough these days.

[Ten-miles final]

Preparing for circling on Bus is more demanding procedure than for conventional aircraft as you have to load FMGS with lot of things you've never thought about flying Boeing. Furthermore it requires extra computer manipulation on downwind.
Even if you decide not to use automation at all you'll have to remember reverting to selected speed as groundspeed mini may arrange a surprise for everybody on short final if you remain in managed speed - on Bus pilots switch off autothrust on very-very rare occasions.
Once again - circling on A requires much more mental resources than same approach on B. Here I see the reason for this attempt to put everything in computer and then just look out of window. Perhaps this strategy is feasible but once one small thing in this chain fails all remaining stuff collapse completely.
I'm quite skeptical to admit captain's mental or any other health problem. To my knowledge all described facts may be easy put into well defined CRM aspects. I saw huge amount of similar scenarios in simulators and once - in real life.

[Neptunus Rex]

I am sorry, Sir , but you have been misled. From the A320 FCOM, the last input into the FMGS is to 'activate the Secondary Flight Plan' (in order to have Groundspeed Mini for the landing runway) which is done prior to entering the crosswind leg. All subsequent actions are performed by PNF on the glareshield knobs or by PF on the primary controls, eg timing; FDs off; AP off; RW Trk (turning base.)

Pretty similar to any other conventional aircraft, wouldn't you say?

[Ten-miles final]

OK645
If you can't see the runway environment, you can't circle.

Right. But in this approach captain tried to put everything into computer constructing PBDs. Why? Because on A this is state of mind and modus vivendi - to properly program computer and then just check what it's doing. Programming computers takes much time - that what I was trying to say.

Rex
Thank you for comment. I fly A for just a little time and never did circling in real flight on A, only in sim. But what is written in my manual:
‐ Early on downwind : Activate SEC F-PLN

[RunSick]

How is it demanding?

PNF activates secondary flight plan. That´s it.

Also, if you could elaborate a bit more on the "lot of things you´ve never thought about flying Boeing"

[aterpster]

OK465:

The straight final segment is 3NM not 6NM, check your guns. Eh

Fortunately, no one who actually flies RNP AR in the U.S. uses those awful charts like the one Zeffy posted. Instead, they use this chart for RNP RNP Y 16L, which is much more comprehensible:


Index of /RNO (http://www.terps.com/RNO)

[Ten-miles final]

Runsick

I have to call PNF to activate SEC FPL or at least crosscheck what he is doing, this requires attention.
Many years ago I started with very old turbo-prop with little automation capable only to maintain constant altitude, so making visual approach was very easy - just look outside and fly.
Almost same applies for 737-200. Next one, 737CL offers some opportunities by FMC to facilitate visual approach constructing some reference waypoints, crosstracks etc. This is very useful but involves programming computer first, ant this may be quite time consuming, especially when done by low experienced pilot.
Finally on 320 pushing buttons is unavoidable time investment.
Perhaps it's old discussion, off-top and wasting time to read.
Perhaps I'm only one here experiencing difficulties on transition from B to A.
That fatal approach, as I can understand from report, was not planned nor executed in proper way. And just very small inconsistencies and A features further aggravated situation up to fatal result. IMHO

[golfyankeesierra]

The FPV (Flight path vector) feature, or "bird", on Airbus makes any visual a walk in the park, making A much better suited for circlings then B, IMO.
But true, having to select sec flightplan on downwind is not ideal.

[Capn Bloggs]

Ten Miles Final, hardly any of that FMS stuff is necessary and is merely a symptom of Magenta-Capture. Like moths to a light and gen Ys to iphones, the almost irresistible allure of the FMS overwhelms the weak. It rapidly becomes not a crutch, but a walking frame. It would appear that this accident is an example of that.

[Ten-miles final]

Capn Bloggs (http://www.pprune.org/members/48133-capn-bloggs)
Agree.

OK645
Yes, 737 NG is equipped with FPV but apart of unreliable airspeed procedure its application is not described anywhere in boeing manuals.

[golfyankeesierra]

B has an FPV on the PFD and in the HUD.
Don't know about the HUD, but the FPV on PFD in B is useless.
I am not biased in the A vs B debate, but the FPV is probably the most useful (and underestimated) tool in Airbus.
Just put the FPV on the runwaytrack bug (no need to adjust for wind) and tail touching horizon means 3degrees path.
You need to have flown with it just once to fully appreciate its value (and B's FPV becomes a laugh after that).

It really lowers the workload in circlings.

[Gretchenfrage]

Nobody really needs a tail to read the FPV on 3deg. What if you want to correct your vector and put it on 2.5 or 3.5 for some time? Where is the tail then?? Either you can read degrees or not.

The FPV is nicely usable on both, A or B.

What is very strange, is the bird presentation on the A when you select FD off.
Suddenly you see a new presentation jingling around the horizon on any side, depending on the wind, the 'cage'.
The real outcome of this feature is the flying pilot chasing the circle to match the cage. By that the only difference I saw, was the range of pitch and bank that was considerably greater than if the pilot would just look outside and take the bird as a simple help every now and then.

Circlings I witnessed on the A were all more of a problem than the ones on the B. Not because the aircraft would handle worse, but because the procedures recommended by the manufacturer and the companies were too automatics-bound. The A pilots were looking inside at least twice the time as on other aircraft.

If you think this increases safety, so be it. I disagree.

[golfyankeesierra]

What is very strange, is the bird presentation on the A when you select FD off.
Suddenly you see a new presentation jingling around the horizon on any side, depending on the wind, the 'cage'.
I think it's the other way around. You get the cage with F/D ON, and I agree that's not useful, but I select F/D off during visuals anyway.

For the benefits of the FPV on A over B, let's agree to disagree. The bird is superior.

[Gretchenfrage]

sure, you're right, it's with FD on ...

with the FD off, the bird is almost the same on A & B

[paparomeodelta]

So we have an uncapacitated, but dominant captain flying like crap. This is the underlying source to the crash.
Give me the options for the F/O given the captains former behaviour. Doing nothing is as we all know not an option, crash axe has already been mentioned...
What would you have done?

[BOAC]

PR - this is (fortunately) an extremely rare situation. There can be 2 cases

1) The Captain has either gone mad and is INTENT on killing everyone.
2) The Captain has 'lost the plot' and is probably going to kill everyone

In 1) it is the crash axe/fire extinguisher if you cannot get c/crew up in time to restrain.

In 2) it depends on the 'attitude' of the Captain - here we appear to have one who wished to intimidate the F/O for whatever reason - perhaps the F/O was the world's best smart-arse and needed 'bringing down' - who knows? Once the C then 'loses the plot' the only option for the F/O is to take control, which would probably be strongly resisted but may well have enabled a climb away and an attempt at 'resolution' at a safe altitude. Sometimes the C in this situation will capitulate and thank the F/O and sensibly hand over control formally - that is, I think, the 'common' result in this 'uncommon' event.

[paparomeodelta]

In 2) it depends on the 'attitude' of the Captain - here we appear to have one who wished to intimidate the F/O for whatever reason - perhaps the F/O was the world's best smart-arse and needed 'bringing down' - who knows? Once the C then 'loses the plot' the only option for the F/O is to take control, which would probably be strongly resisted but may well have enabled a climb away and an attempt at 'resolution' at a safe altitude. Sometimes the C in this situation will capitulate and thank the F/O and sensibly hand over control formally - that is, I think, the 'common' result in this 'uncommon' event.
...this guy obviously was partly "gone", maybe for medical reasons. So how to take over command from a guy who has partly lost it, but still wants to stay in charge?

[stealthpilot]

For those of you who havnt read it, the report is on the Pakistan Civil Aviation Authority website.

:: CAA Pakistan :: (http://www.caapakistan.com.pk/)
On the left click on 'Safety Investigation Board'
Click on 'Investigation' and you can download it.

:bored::uhoh:

[Sunnyjohn]

PR - this is (fortunately) an extremely rare situation. There can be 2 cases

1) The Captain has either gone mad and is INTENT on killing everyone.
2) The Captain has 'lost the plot' and is probably going to kill everyone

or 3) the Captain's behaviour, rationality and judgement has been impaired by some medical reason.

[captplaystation]

That is most probably erring on the side of generosity. Reading the report, one finds that he spent the first hour of the flt berating/belittling his colleague in patronising tones. He then proceeded to build an illegal approach, failed to use the Hdg function, mishandled the aircraft, & totally ignored both the FO & EGPWS exhortations to pull up.
One could indeed argue that he "may " have been incapacitated, but I fear that any incapacitation was more than likely self induced, & limited to being an overbearing old b@stard without the faintest hint of the meaning of CRM.

This is a "classic", which we will no doubt be forced to dissect over the next 10 years on CRM recurrent training. Difficult to believe we will find anything more complex than what I have alluded to here.

[paparomeodelta]

What to do as F/O in these two cases:

1) He´s an old bastard in line with CaptPlaystation
2) He is incapacitated for medical reasons, goes for bad decisions etc...

What would you do? Crash Axe?

Really interested to hear some different solutions how to solve that problem, and maybe rescue some hundred souls...

[aterpster]

papa....

Really interested to hear some different solutions how to solve that problem, and maybe rescue some hundred souls...

Aggressively take control of the airplane, while clawing for sky declare mayday to ATC, telling them the captain has gone nuts and deliberately almost flew into a mountain. They would be on the F/O's side at this point, because the military is seeing it all on radar.

[bubbers44]

A while back I stated this but on a dangerous approach because the captain was high on a short runway with a crosswind wet tried to land long so I put the thrust levers up and pulled up knowing I would be fired but I just wanted to live. He thanked me surpisingly. You have to do what you have to do.

[BOAC]

papa and sunny - an interesting parallel is developing in the recent Italian cruise liner tragedy where it appears the Captain diverted from the 'approved and planned' route and caused the grounding. It would be interesting to know what 'discussions' took place there with his crew.

[Heathrow Harry]

Playstation wrote:-
"One could indeed argue that he "may " have been incapacitated, but I fear that any incapacitation was more than likely self induced, & limited to being an overbearing old b@stard without the faintest hint of the meaning of CRM."

Sounds like the Trident Papa India captain.....

[paparomeodelta]

papa and sunny - an interesting parallel is developing in the recent Italian cruise liner tragedy where it appears the Captain diverted from the 'approved and planned' route and caused the grounding. It would be interesting to know what 'discussions' took place there with his crew.

There is actually an international commission planning to introduce "WTC", water traffic control, so that no dumb cruiser captain can be able to select personal routes for his cruise liner. This actual guy went way off his ideal route, allegedly to "show off" and pass the idyllic island very close. Imagine that in our trade...

Thanks for the options given to a F/O with a crazy or incapacitated captain! Are there more to come?

[BOAC]

There is actually an international commission planning to introduce "WTC", water traffic control, so that no dumb cruiser captain can be able to select personal routes for his cruise liner. This actual guy went way off his ideal route, allegedly to "show off" and pass the idyllic island very close. Imagine that in our trade...From what the owners said in their press conference today that was all in place on that ship - pre-programmed route with an 'alarm' system for deviation.

Thanks for the options given to a F/O with a crazy or incapacitated captain! Are there more to come? Please use your imagination - can you not answer this yourself? You talk, after all, of "Imagine that in our trade...". At age 61 I would have thought you had considered this problem at some stage?

[Sunnyjohn]

Sounds like the Trident Papa India captain.....

Indeed - a point I made in an earlier post where the quote from the report stated that medical reasons (his heart problem) may have affected his judgement, and temper.

[paparomeodelta]

Please use your imagination - can you not answer this yourself? You talk, after all, of "Imagine that in our trade...". At age 61 I would have thought you had considered this problem at some stage?

...and getting nearer and nearer 62 ;)

Dear BOAC, thanks for all your insightful comments during the years (no irony!).

Of course I have considered it.

[4Greens]

Last contribution to this post. As I stated previously there are only two things you know about an accident. There is never a single cause and there is always human error. In this case the thread name is wrong. An accident such as this is not purely caused by the Captain - same for cruise ships. Training, checking, monitoring, regulations and so on are all part of the mix.

[BOAC]

Para - I wish you many more years, but I really do not see where all this is getting us. We have an extremely rare event. Another event where there cannot be an 'SOP'.

[paparomeodelta]

Para - I wish you many more years, but I really do not see where all this is getting us. We have an extremely rare event. Another event where there cannot be an 'SOP'.

Just because there cannot be an SOP, it is interesting to hear different angles on the subject.
With all respect, if you find it uninteresting, you can leave the thread. But not decide what me and some others (see previous notes) find interesting.

[Machinbird]

OK, my two cents on what PNF should have done.
Just stiff arm the throttles after telling the Captain to go around first.
It would force a climb back into the clag where a circling approach could no longer be considered an option. It would be very hard for the Captain to override a locked arm.
They would then go through the regular missed approach and have a 'discussion' about their next options.

Same for the Mangalore accident.

[fireflybob]

One of the major strategies to prevent hijack it to stop potential terrorists getting on the aircraft in the first place - as we know this may not always be 100%.

So in this case I see a parallel. If this Captain was known to be overbearing etc then what was he doing on the aircraft in the first place? What procedures do airlines have in place to spot those who might be "mentally impaired" as crew members and stop them getting on the a/c in the first place?

If a First Officer knows that a Captain is going to be impossibly difficult to deal with then perhaps he should just refuse to fly with him. If enough did this then the message would get through.

Having to take action in the air at the eleventh hour is trying to bolt the stable door after the horse has escaped.

[Gretchenfrage]

If a First Officer knows that a Captain is going to be impossibly difficult to deal with then perhaps he should just refuse to fly with him


In such regions a refusal to fly with a half god simply costs your job. The same goes with taking over command. You'd save your butt, however you'd lose your job. If captains like the one in question still are on the line with such a reputation, this means they are protected. Most probably by superiors with the same attitude towards authority. It's an epidemic that is hard to root out. In the west it is also hard to imagine, but it it still looming in these regions.

The only defense in such circumstances would be to shove the levers up to TOGA, say "yes. Sir. GoAround understood, TOGA set" and later apologize sincerely and pretend having definitely heard the command "GoAround" as in this situation it really made sense. If it was not intended, then apologize sincerely again and say it was a misunderstanding. The ego of the maniac is intact and so is your carrier. Additionally it will be HIM trying to avoid to fly with you again.

[RunSick]

GF
That´s a good one:D
I´ll write it down on my personal SOPs

[grounded27]

Man, operating as a Flight Mech for several years. Sitting in the cockpit, listening to countless pre flight briefings I gained respect for the Capitan who asked me to ignore the "silent cockpit" rule if I saw an abnormality as I was an extra set of eyes who knew the aircraft and simple flight law.

I also flew with several Capitan's who scared the Shiite out of me. As a result those few Capitan's held a silent cockpit for the duration of a 8 hour leg. I could go back and rest on the cargo or in a seat, always felt sorry for the poor F/O and scribe who had no choice in the matter.

[BOAC]

Just because there cannot be an SOP, it is interesting to hear different angles on the subject.
With all respect, if you find it uninteresting, you can leave the thread. But not decide what me and some others (see previous notes) find interesting. - invitation noted, but I can assure you I do not find it 'uninteresting'. I am actually more interested in the particular axe you appear to be trying to grind.